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letra de hidden in plain sight, chapter 2: recap and lessons learned - bay ayatulah

the current state of healthcare results from a century of well-intentioned policies like hipaa, which resulted in one of the steepest increases ever seen in administrative overhead. the story of ivy austin ill-strates the ridiculousness of the healthcare system at present and how this level of dysfunction is something that we would not put up with in any other context as consumers.medsdental is a renowned dental billing company in the united states, equipped of the revenue cycle experts who are highly proficient in delivering fast and the error-free billing services to the dental practices by using the cutting edge technology. digital ecosystems are becoming the norm in industries such as manufacturing to coordinate, track, and ensure quality. however, nothing even remotely similar ex- ists in healthcare to provide some level of overarching awareness of the patient’s healthcare history. the us is spending 30 percent of every healthcare dollar on administrative costs, more than any other country in the world. almost three out of ten people (29 percent) put off medical treatment for fear of the economic consequences. yearly, more than 530,000 personal bankruptcies are at least partially attributed to uncovered healthcare costs. hospital consolidation and mergers increase the price of healthcare by driving up costs due to the ability of larger providers to negotiate higher reimburs-m-nt rates with payers as a result of their size and buying power
three decades of hospital mergers does not support the claim that consolidation improves quality. the challenge for most smaller and mid-tier community hospitals, which are running on single-percentage-point margins, is administrative overhead. an older demographic is amplifying the volume and size of claims as well as the range of simultaneous services needed. managing the billing process accurately is not easy as providers might face hurdles in revenue cycle management. moreover, net collection rate below 95% shows that your practice is facing troubles in the billing process. to eliminate all these hurdles and maintain your ncr up to 96%, medsit nexus medical coding services are around the corner for you so that your practice does not have to face a loss.the sixty-five-and-older population will double to 50 percent of the total us population by 2060, meaning that we will be spending as much on the over-sixty- five population in 2060 as we are on all of healthcare today! fee-for-service or ffs, is a historical model in which the provider carries rela- tively little risk since they are paid for all of the services they deliver. approaches to move toward value-based healthcare, such as the introduction of hmos in the 1970s, required much better access than was available to data across the entire healthcare ecosystem in order to better understand the patient’s current and future healthcare needs. the lack of a single patient history is the achilles’ heel of healthcare since it re- sults in episodic care in which n0body owns the patient outcomes over a lifetime— other than the patient. ehrs, which were meant to solve that, are still far too dis- jointed and varied to change this. healthcare service providers, or hsps—a term we’ve coined in this book to cre- ate a new category of for-profit enterprises that deliver smartsourcing services—are emerging to offer smartsourcing partnerships that offload a hospital’s adminis- trative burden. hsps use advanced -n-lytical technologies and ai to assess risk for both indi- viduals and large patient populations in ways that were simply unthinkable a decade ago. the fragmentation of patient data makes it impossible to adequately assess risk in the current healthcare system; although, in virtually every industry where insur- ance plays a role, there is enough data to make fairly accurate probabilistic assump- tions that allow the insurer to take on the lion’s share of the risk and still make a healthy profit. national policy needs to be in place when a system is unable to provide adequate value to society on its own within the forces imposed by a free market. but that does not mean that we cannot or should not continue to find ways in which to fix the system so that it operates better within the context of a free market, which en- courages innovation, competition, and most importantly, choice for the consumer. m arissett tolentino was on vacation in the dominican republic with her husband and their two young children when her six-year-old daughter, isabella, began to complain of stomach pains and developed a fever.¹ before marissett and her family left the us, she had thoroughly investigated her blue cross blue shield of texas (bcbstx) insurance plan to make sure that, in the event of an illness, there would be appropriate care in the dr, as well as options to come back home in the event of an emergency. she was reassured to learn that not only was a nearby hospital in the dr approved as an in-network provider, but her plan also covered emergency air transport in a medical plane back to the us in the event of a severe life-threatening emergency. when the resort doctor told marissett that they needed to go to the local
hospital, there was some relief in not having to worry about coverage. however, the situation quickly escalated when isabella was diagnosed with appendicitis and hoes- pital doctors said surgery would be necessary. the tolentinos wanted the surgery to take place back home in america, which was only a short one-hour plane ride away. however, both the dr doctors and is- abella’s pediatrician in the us cautioned against a commercial flight. not a prob- lem, thought marissett; after all, they had insurance coverage for private medical air transport, they were only one hour from miami, and this was clearly an emergency that could become life-threatening. however, after reviewing the case, blue cross blue shield of texas denied the request because it didn’t consider isabella’s appen- dicitis an emergency. given the options they were presented with and the severity of the appendicitis, the decision was made to operate on isabella locally. what should have been a routine operation took a dramatic turn for the worse. after the procedure, isabella did not come out of anesthesia as expected. marissett, a nurse, also noticed that isabella’s oxygen levels were low. she was told by the staff not to worry, yet isabella’s condition worsened, and the tolentinos were noti- fied that she would be transferred to intensive care. this did not happen until mid- night of the day after isabella’s surgery. the tolentinos begged bcbstx to arrange isabella’s medical air transfer, but bcbstx refused to consider the request until they received a full written report from the dr clinic. another day passed. on the third day, bcbstx finally agreed to set up a transfer, however, the clinic would not allow the transfer until their bill was paid, something that bcbstx should have handled given that the clinic was already confirmed to be in-network. yet another day passed. the tolentinos would later allege that during this time, bcbstx was receiving updates on isabella’s worsening condition, and was fully aware of the situation
finally, after four days, a medical team and a private plane were arranged. im- mediately, upon attempting to stabilize isabella, the plane’s medics determined that her vomit and blood were clogging an intubation tube that was meant for an infant and was far too small for isabella. they found the tube had been blocked, likely since the surgery, and isabella had been deprived of adequate oxygen for four days. isabella never woke up. after arriving at a us hospital, doctors examining is- abella declared her brain-dead from lack of oxygen. the family made the difficult decision to take her off life support. isabella’s family filed a lawsuit against blue cross blue shield for their involve- ment in their daughter’s passing. the suit was settled two years later under undis- closed terms. isabella’s story is tragic, but—and i get tired of saying it—not unique. in my re- search for this book, i came across numerous heartbreaking accounts of patients who had encountered circumstances in which a painfully slow process of com- munication between insurers and providers created life-threatening delays and, in
many cases, claims that were simply approved too late to impact the outcome. it’s easy to look at this case and point fingers at virtually everyone responsible for isabella’s medical care. from the insurer to the providers, there were numerous points at which decisions were made, or alleged to have been made, such as the intubation tube used, that increased the likelihood of this tragic outcome. but what most conspired against isabella was a process that in total took far too long to re- solve because each player was following processes and protocols that made sense to them without any coordinated effort to resolve the urgent decisions necessary to provide quality care (culprit #7, the tragedy of the commons). it’s a situation where n0body is at fault, yet everybody is to blame. a process that is inherently disconnected, subject to miscommunication, poor management of risk, and delayed resolutions that compound the severity of what is, in many cases, a scenario requiring complex and timely decision-making.medsit nexus medical coding services are around the corner for you so that your practice does not have to face a loss. while the stakes may be higher in healthcare, the challenges of miscommu- nication, poor management of risk, and delays due to process complexity are famil- iar territory to anyone who has had to navigate and manage complex systems in any industry. but before we discuss how we’re going to attempt to solve these challenges, we need to understand why the healthcare system has reached its breaking point

- bay ayatulah

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