Blessed with the luxury of time, I opted to ride the Amtrak down to New Orleans for this year's MGMA conference. I love taking the train because it helps me stay connected in so many ways that air travel can not-both by witnessing the ever-changing landscape out the window (we're zipping through central Mississippi as I write this, a land of green if there was one) and by hob-nobbing with other passengers in the dining car..

Here I am invariably reminded how vast the health care industry is. You don't have to sit very long before encountering someone who works in it. The MGMA-bound physician from Milwaukee in the opposite cabin gave me an earful about the EHR--it upends their practice's workflow to no end, he said. And it's easy to find people outside the industry who have concerns about healthcare from the consumer point of view. The world of the electronic health record that so riled my traveling physician companion is pretty remote to these folks.

But people are concerned about rising costs and the increasingly tangled ways in which they interact with the industry financially. Just this past week, I tried to bone up on the Medicare options available to consumers--it was part of an article on long-term financial planning--and I had to stop reading. Too complicated. This financial complexity threatens to derail the patient-provider relationships we all value so much. And as the economy worsens, it's a relationship that can easily turn adversarial.

I recently filed an article that will appear in our December print edition that analyzed what providers are trying to do to improve collections and cash flow. As one source pointed out, hospitals and providers are now, in essence, becoming financial institutions, lending out money, arranging payment plans, and monitoring accounts. They perform services now, and collect later. Less than honest consumers may attempt to game the system. Here's the scenario one revenue cycle executive described: A. Patient loses job. B. Patient quickly books appointment for over-due procedure. C. Patient presents old insurance card. D. Provider accepts, only to later to find the patient is no longer eligible. E. Unpleasant collections effort follows, maybe bad debt.

It's no wonder that providers are looking for systems that can do upfront eligibility checks. Others are implementing software programs that will estimate the patient obligation, a calculation that becomes more difficult as health plans become more specialized and shift more risk back to patients. Still others are deploying contract monitoring software that works in conjunctions with claims systems to assure health plans are living up to their obligations. The focus is, increasingly, financial. It's an orientation borne of necessity, of course. But it will entail a rethinking of our rights and responsibilities on all sides of the provider-payer-patient equation.

I just hope those Medicare options become easier to understand by the time I'm ready to enroll. When the doctor becomes a collections agent, we all lose.


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