It's a Surprise

We are, it appears, shocked -- shocked! -- that there are "surprise" bills in healthcare.  That is, bills from out-of-network healthcare professionals, even when patients thought they were going to in-network professionals/facilities.  The problem is bad enough that even our deeply divided Congress has bipartisan agreement that it should act (although whether it will, of course, remains to be seen). 

Of course, surprise billing shouldn't come as a surprise to anyone who knows much about healthcare; it is more of a symptom of problems with our healthcare system than a problem itself. 

Credit: LAUREN GIORDANO / THE ATLANTIC

Kaiser Health News/NPR deserve much credit for getting more attention for the issue, with their Bill of the Month crowdsourced investigation.  They profiled a number of people who had done their best to follow their health plan's rules, only to subsequently find themselves liable for tens or hundreds of thousands of dollars of uncovered bills, often from healthcare professionals they had not chosen and might not even been aware they'd used.   

Sarah Kliff of Vox did similar work with her focus on outrageous emergency room bills. 

Some patients ended up in collection -- even having liens placed on their houses -- due to these bills, although some had their bills reduced once KHN/NPR shone the spotlight on them.  About half of the states have already enacted some type of legislation to combat these kinds of bills, although no one thinks we've quite found the "right" solution yet (e.g., states can't regulate self-funded employer health plans). 

Like most things, the "solutions" will lead to other problems, some of which are foreseeable now and some of which are not.  E.g., the money to pay these bills has to come from somewhere; either healthcare professionals get paid less, or health plans pay more (which mean consumers pay higher premiums).  It might lead to health plans making their networks skimpier, knowing they can always rely upon the new "out-of-network" prices. 

Many believe surprise billing is a problem of transparency: make healthcare prices more transparent, and there won't be any surprises.  The current Administration has pushed for this in hospitals and prescriptions, and are looking to widen these efforts.  Unfortunately, it is neither clear what those prices mean, nor how many consumers will be able to understand them.   

There's no doubt that surprise bills are a shameful consequence of the profit-seeking nature of too much of our healthcare system, especially when it comes to charges from professionals/organizations that patients had no choice in (e.g., ERs, ambulances/air ambulances, anesthesiologists, radiologists,
lab/pathology).  But it may be not so much about greed as it is arrogance. 

Take "consent to treat."

Example of e-signature form

When you go to a healthcare professional or visit a healthcare facility, chances are you'll be asked to sign a consent to treat form.  It may be called something different, and may include "consent to bill" or have be asked to sign that separately.  You may not bother to read the language; in my local healthcare system, you're asked to electronically sign on a keypad, without actually seeing either the document or your signature.   Whether you read it or not, you are not getting services until you sign.

The wording may vary, but the thrust of what we are being asked to sign is this:

• You agree that they can treat you, reserving their right to involve others in your treatment should they choose;
• You may agree to a specified treatment, but they reserve the right to perform other treatments in addition to/in lieu of it should they deem them medically appropriate;
• You agree that they can bill your health plan, but also agree that you are responsible for any costs not covered by the health plan, no matter how large they are or where they come from.

 In this kind of environment, surprise billing is not a surprise, it is inevitable.

Imagine if buying a car was like this.  You might go into a car dealer with a fairly good idea of what car you wanted, with what features and at what price, but instead you agree to let a car buying specialist handle the purchase.  He/she may seek to get you what you wanted, but might decide that you needed other features, perhaps even a different car, regardless of cost to you, and might even bring in some other car buying specialists whose expertise you also have to pay for.  "Sticker shock" would take on whole new kinds of meaning. 

Car dealers would drool to be able to sell like healthcare. 

Our healthcare system is based on the assumptions that our healthcare professionals know what is best for us, and act in our best interests.  That may have once been true, but, sadly, it no longer always is.  Patients are more armed with information, and often have clear preferences and expectations.  Healthcare professionals and organizations have learned how to maximize revenues, too often without thinking enough about where those revenues come from. 

Credit: Marketwatch/iStockphoto

It's one thing to gouge health plans (e.g., Rand's recent study on hospital pricing), even Medicare/Medicaid, since the impact on premiums/taxes is further downstream and more widely distributed, but increasingly it's happening directly to consumers.  Thus the furor over surprise billing, as well as high deductibles.

 Sure, let's do something about surprise bills.  It's bad and shouldn't happen, at least not to the extent it is.  But let's not pretend we're really solving anything.  It's only a band-aid on bigger issues.  Likewise, we should have more price transparency, but unless we simplify and clarify healthcare prices, it's not going to do much -- especially when it often isn't clear what we need prices for, or from whom. 

Healthcare needs to stop using things like consent to treat agreements that gives professionals/ facilities carte blanche, and start being open and honest with the people it supposedly is serving. 

That'd be a surprise.

The Health Tech Our Toddlers Should Never Know

Joanna Stern wrote a fun article for The Wall Street Journal: "The Tech My Toddler Will Never Know: Six Gadgets Headed for the Graveyard."  She selects gadgets she predicts going to be outdated as soon as 2030, making them as unfamiliar then as DVDs and VHS tapes are now to her two-year-old.

I'll touch upon her list shortly, but my immediate thought was about health tech's equivalent list.  There certainly is a lot of health tech that should be headed to the graveyard, but, knowing healthcare's propensity to hang on to its technology way too long, I had to modify her more optimistic headline to say "should" instead of "will." 

One can always hope. 

Here's Ms. Stern's list:

1. Cords and ports: "Our homes, cars and offices will have all the wireless chargers integrated," Sanjay Gupta of the AirFuel Alliance told her.
2. Credit cards and keys: She points to efforts like Amazon Go, where sensors, camera, and AI keep track of what you are doing and make these unnecessary.
3. Oversized smartphones: "The private displays of the future will be in glasses and contacts; public displays in the physical world will be on most surfaces," Alan Kay predicts.
4. Dedicated cameras: "In a decade, using a dedicated camera will seem as quaint as placing a needle on a record," says Ms. Stern, with ubiquitous embedded cameras rendering them outdated.
5. Living room boxes: "Instead of a dedicated box with a DVD drive and lots of graphics horsepower, the games and the computing power will live in the cloud," she believes..
6. Smart speakers: As Ms. Sterns sees it, "Microphones, speakers and voice assistants will live all around us—in our kitchen appliances, car dashboards, computers, glasses, showers and more."

Pretty cool list, and hard to argue with.  So, in return, here's my healthcare tech list (not all of which are gadgets per se):

1.  Faxes:  You knew it had to be at the top of the list.  Anyone under thirty who knows how to work a fax machine probably works in healthcare.  The reason faxes persist is because they supposedly offer some security advantages, but one suspects inertia plays at least a big a role.

There are other options that can be equally "secure," while making the information digital.  CMS Director Seema Verma has called to make doctors' offices "a fax-free zone by 2020."  That doesn't appear to be happening, but 2030 seems like a realistic goal.

2.  Phone Trees:  We've all had to call healthcare organizations -- doctors' offices, testing facility, health plans, etc.  Most times, you first have to navigate a series of prompts to help specify why you are calling, presumably to get you closer to the right person.  There are probably studies that show it saves money for the companies that use them, and perhaps some that even claim its saves customers time, but this is not a technology most people like.

I don't want to have to figure out how to navigate the phone tree.   Honestly, I don't want to make those mundane, administrative phone calls -- which healthcare seems to be full of -- at all.  By 2030 I want my AI -- Alexa, Siri, etc. -- to deal directly with the companies' AI to spare me from phone trees. 

3.  Multiple health records: I have at least five distinct health records that I know of, only two of which communicate to the other at all.  For people with more doctors and/or more complex health issues, I'm sure the situation is even worse.

EHRs are old technology, the cable of healthcare.  They're oriented around the people delivering care, and around what happens in the office/facility, rather than the person whose health they are supposed to be tracking or where most of that health happens.  The technology exists to collect a broad range of health data for each of us, on an ongoing basis, make sense of it fo us, and communicate it as appropriate to the healthcare professionals who need it.  By 2030, we should each have a single health record that reflects the broad range of our health.

4.  Stethoscopes:   You've seen them. Your doctor probably has one.  Find the oldest photographs of doctors that exist and you might find them with stethoscopes; they are that old.

"It’s a relic. It’s rubber tubes,” Dr. Eric Topol said about stethoscopes.  "It has very little utility compared to how it continues to be so highly revered.” It's not that they are useless, but as it is that there are better alternatives, such as handheld ultrasounds or even smartphone apps.  For Pete's sake, people are working on real-life tricorders.   By 2030, seriously, can we be using its 21st century alternatives?  

5.  Endoscopes: Perhaps you've had a colonoscopy or other endoscopic procedure; not much fun, right?  We do a lot of them, they cost a lot of money (at least, in the U.S.), and they involve some impressive technology, but they're outdated.

By 2030, we should be using things like ingestible pill cameras, with ingestible robots to take any needed samples or even conduct any microsurgery.  These are technologies that exist, should get both better and cheaper, and would certainly make patients' lives easier.

6.  Chemotherapy: Chemotherapy is literally a lifesaver for many cancer patients, and a life-extender for many others.  We're constantly getting new breakthroughs in it, allowing more remissions or more months of life.  But it can pose a terrible burden -- physically, emotionally, and financially -- on the people getting it.  The side effects can be painful at best and devastating at worst,.

Chemotherapy has been likened to carpet bombing, with significant collateral damage.  Increasingly, there are alternatives that are more like "smart bombing" -- precision strikes that target only cancer cells, either killing or inhibiting them.  With targeted therapies, perhaps delivered by nanobots, we can have much less drastic adverse impacts.  By 2030, perhaps cancer patients won't fear the treatments almost as much as the cancer.

Nanobots fighting cancer.  Credit: Healthline

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Healthcare certainly has no shortage of technology that we should hope today's toddlers will never have to use or experience.  The above are just six suggestions, and you may have your own examples.  We can make these happen, by 2030; the question is, will we?

I Am Not a Transaction

I filled a prescription today at the drugstore; my receipt -- for that one item, paid in cash -- was five feet long.  I know; I measured it.  You can probably guess what chain that drugstore was part of.  This issue has been covered extensively before, such as Rachel Sugar's Vox investigation last fall.

Now, I know that, in this case, there are digital options, and that the company claims they cut the length of their receipts by up to 25% years ago, but, honestly, if this was the only issue, I'd just keep throwing them away (after letting my wife peruse the coupons, of course).  The trouble is, I also know from experience that I'm going to get a 4-6 page explanation of benefits (EOB) from my health plan just for this prescription. 

It's not the wasted paper, it's not even the volume in itself.  It's how healthcare organizations keep treating me not as a person, not even as a patient, but as a transaction. 

Credit: Lauren Giordano/The Atlantic

In the drugstore case, the receipt is less about explaining the transaction I just had with them and more about enticing me to buy more from them, with coupons galore (no matter that they're really targeted at my wife, not me, nor that they often are for products we never buy).  In the EOB case, well, I worked for health plans for many years yet still usually struggle to understand what they've covered and why. 

Annotated hospital bill
Credit: Patrick Slawinski, US News & World Report

Similarly, my bills from my other healthcare professionals are more focused on ensuring my account with them is fully paid up than in explaining why they are billing me what they are.  It takes some detective work using the EOB and their bills to form a hypothesis about why I'm supposed to be paying what I'm being asked to. 

Many in the healthcare system assert that EHRs are not more user-friendly because they were built more to facilitate billing than to support clinical work.  I can't attest to that, but it would surprise me if it wasn't true, because almost everything in our healthcare system revolves around billing. 

I.e., is our universe of diagnostic and procedure codes expanding as rapidly as it is because we need that level of precision to understand our health, or to ensure that the people coding them can squeeze every possible dollar from whomever is paying?  Why do hospitals still use chargemasters that rarely are anywhere near the actual cost or negotiated prices?  Why did so many healthcare professionals and organizations need federal incentives to acquire EHRs, but not to move to electronic billing or scheduling systems (which most did decades ago)? 

It's all about the transactions. 

There probably are examples of things happening with our health that can be considered a transaction, a one-and-done event that has no relation to any other health issues -- past, present, or future.  But I suspect that is rare.  Our health is holistic, a function of everything that is happening, has happened, or will happen to us.  When it comes to our health, transactions are part of the story, but they aren't the story. 

You just can't tell that from most of the communications we receive about our encounters with the healthcare system.  Too often, they are about the money: how much who is going to get paid by whom.

We should be doing better.  Each touch with a person using the healthcare system is an opportunity to educate, to explain, to try to make things simpler.  Bills, receipts, EOBs can and should be part of that.  If a healthcare organization gets negative feedback about those kinds of transaction-driven touches -- as most probably do -- then maybe it's time for them to stop thinking so much about what that organization will get from that transaction and more about what that person is going through that caused the transaction.

I was excited to read a Fast Company article about receipts getting an extreme makeover.  Susie Lu, a Netflix senior data visualization designer, put her skills to use:

I was compelled to think of ways that data visualization could be used to redesign everyday experiences.  Of the use cases I had brainstormed, the receipt was the idea I was most excited to play with first.

Credit: Susie Lu

Her redesign updates receipts by showing a bubble chart at the top categorizing spending, following by the standard itemizing, but with each item accompanied by a bar indicating how expensive it was relative to other items in the same category. 

Ms. Lu was operating under several constraints.  She used a low-resolution thermal printer, the kind used in most retail stores.  As Fast Company noted, the printer couldn't even draw horizontal lines, hampering the images it could be coaxed into producing, and the receipt paper doesn't allow for great resolution. 

Despite those constraints, Fast Company raves:

But the final result is fantastic. It’s clear, helpful, and a bit quirky–a perfect trio that would make it a valuable design for any big grocer trying to humanize its customer service a bit

For "big grocer," substitute "healthcare organization."  Think of what my drugstore receipt, with its five feet of available paper, could have shown me.  Think about what Ms. Lu could have done under fewer constraints.

Ms. Lu didn't start with healthcare in her attempt to redesign everyday experiences, but I wish she would have.  More to the point, I wish others would.  As she has demonstrated, data visualization is sorely underused in everyday experiences, and, as I've previously discussed, perhaps nowhere is it as badly needed as in healthcare.  Healthcare is confusing, full of data, and all-too-often designed around the people providing the care than the people receiving it.  It needs all the data visualization it can get.

Design in healthcare has gotten much more attention in recent years, such as from Dr. Joyce Lee, Dr. Bon Ku, or Stacey Chang.  Indeed, Dr. Ku's great quote is: "Everything in healthcare is design."   Design isn't about making things prettier -- well, it's not just about that -- but about making things easier to use and easier to understand. 

Even receipts.

When designing anything for healthcare, we should start with this: healthcare may be full of transactions, but we are not those transactions, and they shouldn't define us or our interactions with the healthcare system. 

Can I Have My Time Back?

If life is, as William James suggested, what you pay attention to, then healthcare takes up too much of our lives. 

Health, of course, is supposed to be an integral part of our lives, but seeking and/or receiving health care is not supposed to be.  Our healthcare -- a.k.a., medical care -- system is becoming too much of a focus of our lives.   

Credit: Cloudpixel

Think about just the time we spend that revolves around healthcare:

• we wait to get an appointment with a healthcare professional;
• we wait at the healthcare professional's office/facility;
• our actual time with the healthcare professional is usually shorter than we'd like, and we often feel he/she is too distracted (by their EHR and/or time constraints);
• if the healthcare professional orders a prescription, a test/procedure, or a follow-up visit (and he/she probably will do at least one of those things), we then have to wait to arrange those, and wait there all over again;
• if we get a test, we have to wait to get the results, often until the healthcare professional has reviewed; 
• we wait in between visits, often not quite sure if what we're feeling is to be expected or when we should take what action other than to go on waiting;
• we wait for our healthcare professional to bill us for their services, and for our health plan to decide how much we actually have to pay;
• if we happened to be hospitalized or in a nursing home, our time is all about waiting, never quite sure when what is going to happen to us.

Once you have a encounter with the healthcare system, you're probably going to have another.  Once you have an encounter, you're probably going to get a prescription, and, at some point, at least a test.  Once you get a test, you're likely to need more tests.  Do enough tests and something will be found, leading perhaps to more invasive action. 


Healthcare becomes self-perpetuating. 


And, of course, many of us spend way too much time worrying about how we're going to afford to pay for health care we've already received, or worrying about how we would pay for it should something "major" happen to us. 

We want to spend our lives doing things that are important to us.  We want to spend time doing things that make us happy or that help the people we care about be happy.  We begrudge spending time on anything else. 

To be sure, we spend time on many things we don't especially enjoy -- we go to work, we exercise, we go to the grocery store, etc. -- but they are in furtherance of the things that matter.  Getting healthcare falls into that category.  But some people enjoy working, some people like exercising, and some people enjoy going to the grocery, but I doubt many people enjoy getting healthcare. 

We may enjoy the outcomes of healthcare -- hopefully, feeling better -- but we rarely enjoy the process of healthcare.  That's why that process should take as little time away from the rest of tour lives as possible.   

If I like Avengers movies, I'm delighted when I find that Avenger's Endgame is three hours instead of two; that's extra time I get to enjoy it.  Same for overtime games in sports.  But I don't feel that way when, say, meetings run long, and I definitely don't feel that way when I have to wait in the healthcare system.  Of my limited time, that's not how I want to spend any extra minutes. 

Healthcare needs to respect our time more.  Healthcare needs to make us feel like our time is more valuable than the time of the people working in it.  Healthcare needs to make us feel like it is ready for us, when we need it, not like it is somehow doing us a favor and it will get to us when it can. 

Just recently, Tesla announced that it was going to keep track of certain components for its cars in real-time, let you know when it was time to replace them, and ship the replacement parts to the closest service center.  "Like skipping the doctor and going right to the pharmacy," Tesla says.

Except, of course, healthcare doesn't do anything like that.  Not yet.

NEJM Catalyst featured a talk by Judith Baumhauer of the University of Rochester Medical Center about the importance of using patient-reported outcomes to "predict the future."  It uses such information to help patients understand how they might benefit, and how they might expect to progress, from different courses of treatment.  "We needed for our patients to tell us how they’re doing,” Professor Baumhauer said. “We didn’t like telling them how they’re doing. We like them telling us.”

Figuring out how to identify which patients would benefit from which treatments "...is the holy grail of health care,” Professor Baumhauer believes. “We’re going to do preventative actions to improve the health care that we provide for patients.”

Don't waste our time collecting information that won't be used to help our care.  Don't waste our time with treatments that won't help us.  Don't waste our time fixing problems that could and should have been prevented.  Don't waste our time, period. 

Give us more time to spend on our health, and less on our health care.  Give us more time living our lives, and less dealing with the healthcare system.  And, when we do have to interact with the healthcare system, treat our time as precious, just like our health.

The hot phrase in healthcare for the past several years has been "patient-centered."  The idea is well-intentioned, but misses the larger point.  We don't want to be patients.  We don't want to spend time being in the healthcare system.  We're people, and the goal of the healthcare system has to be maximizing the time in, and quality of, our lives outside it.

It's bad enough that healthcare has so much of our money, but it's even worse that it takes so much of our time.