Over my six-month hiatus from this blog, many things have changed in the health care industry. Two of the most significant have been the delay of the ICD-10 implementation and the Supreme Court’s review of the Affordable Care Act.
But one thing has stayed constant: We still seem to be struggling with two divergent views on how to improve health care in this country. Vested interests and ideologies are as deeply ingrained as they were six months ago, and the numerous studies and counter-studies may not have done much to shift opinion one way or another.
My thoughts: However well-intentioned the ACA might be, and however many positive steps forward it may contain, it by itself will not be enough. The fundamental change needs to behavioral, and it should happen on both sides of the aisle—I’m not talking about Democrats and Republicans, but consumers and care providers. Market conditions will determine the course, as they always have.
Let’s look at two basic scenarios:
* All the data points that I have seen over the last few years seem to indicate that the individual markets are here to stay. So why worry about the constitutionality of state insurance exchanges? Why not focus on the core ingredient, i.e., theindividual? Why not improve the service offerings for the individual? Why not provide more telemedicine capabilities? Think about a single mom who has to take a crying toddler to the pediatrician’s office through a clogged beltway, and then shell out a $40 co-pay. If the physician is willing to see the child through a Web-based telemedicine portal, the mom may be willing to pay a few extra dollars via the co-pay for the convenience while not having to spend money on gas. The physician could then prescribe online, and the pharmacy could deliver the medicine to the patient’s home. Everybody is happy, including mom, the physician who gets a slightly better (not to mention immediate) reimbursement, and the insurer, which could possibly get away with a slightly lower reimbursement to offset the additional co-pay. This is not rocket science. It has been done many times in other industries--banks broke the code on convenience 30 years ago. Health care can now do the same.
* Mobile devices have become as much a part of the culture as TV. So why not use them? Why not create real-time health care app stores that provide functionality, such as mobile member liability estimation at the point of service to avoid confusion about EOBs and post-procedural follow-ups, recouping costs that add to administrative overhead? More pervasive clinical decision support so that the physicians can provide improved quality of care and eliminate redundant procedures? Integrated and real-time claims adjudication so that administrative load and infrastructure costs could be reduced on the health plan side (not to mention the confidence it could elicit from providers in knowing what they will get paid for and how much)? Imagine how much the consumer would appreciate the fact that before they go through a procedure, they know exactly what they would be paying for; they know what process of elimination the provider went through to arrive at the procedural conclusion; they know that there likely won’t be a need for any redundant procedures as all providers have access (based on consent) to all their clinical information; and by the way, they know they can pick up their prescription on their way home and pay for the cost-share through their checking account automatically; and they know they will be able to get an easy-to-read integrated report on their mobile device. Utopia.
If such services could be provided, wouldn’t the need for trying to change the system through mandates become less and less relevant? The arguments and counter-arguments become moot, and we can actually focus on reforms. Granted there will still be the need to accommodate the population that is hard-strapped for cash to pay for these services; and yes, there should be provisions to support them. But the vast majority of inefficiencies could be easily weeded out simply through a slightly creative and non-traditional thought processes, thereby creating surplus dollars to support those who actually need it.
That brings me back to my headline, “Health Care: A Not Too Distant Future”.
To me that future will look something like this, using the need for a procedure as an example: A consumer has symptoms; the consumer consults via telemedicine with the provider of choice (who could be recommended through an intelligence portal supported by the consumer’s insurer); the patient knows exactly what he/she needs to pay and can do quick research on the provider’s capabilities as well as the typical market prices for that procedure; the consumer agrees; the provider schedules the procedure; the insurer does an automatic pre-auth; the provider e-prescribes; the consumer pays his/her share either through a personal account, or redirects to an assistance agency in cases of subsidized consumers; the procedure takes place on schedule; the associated post-op services are automatically pre-authorized; the claim is auto-adjudicated; the co-pays are automatically deducted from the consumer’s HSA/FSA account; clinical records are automatically updated to reflect the latest procedure and its impact on future care service; and the consumer is auto enrolled into post-op care programs.
And all of this on a tablet while that consumer is attending his or her daughter’s soccer game.
Much of this is possible with the current state of technology without having to worry about the outcome of the Supreme Court’s deliberations on the ACA.
All it will take is a technology-savvy, forward-looking organization with somewhat deep pockets and willingness to forego immediate-term profit concerns in lieu of long-term windfall. Any candidates out there?
Rajiv Sabharwal is director at Deloitte Consulting LLP, a member firm of Deloitte Touche Tohmatsu Limited (DTTL), a UK private company limited by guarantee.
Disclaimer: This publication contains general information only and is based on the experiences and research of Deloitte practitioners. Deloitte is not, by means of this publication, rendering business, financial, investment, or other professional advice or services. This publication is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor. Deloitte, its affiliates, and related entities shall not be responsible for any loss sustained by any person who relies on this presentation.
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