Consumerism has changed the face of healthcare, and rightfully so. Increased financial responsibility has shifted the way individuals choose, consume, and pay for their care. While our industry has worked diligently to improve the patient experience from a clinical perspective, the same cannot be said about improving the patient experience from an administrative perspective.
How administrative inefficiencies impact the patient experience
Even with the billions spent to date implementing electronic patient records and digital solutions like patient portals, the progress these tools were intended to achieve—improved outcomes, lower costs, and creating a better patient experience—has yet to be realized. Healthcare still struggles with data silos and disjointed administrative processes that are making the patient experience worse, not better.
Below, we’ve outlined three main administrative challenges that impede patient satisfaction and a solution that promises to address them all.
Unnecessary processes that impede access
Our healthcare system is extremely challenging for consumers to navigate. We fault them for not having a primary care provider and for not taking proactive steps to manage their health. Yet, we make it difficult for them to do so.
Consider the scheduling and registration process. We ask patients to provide their insurance information, either over the phone or through the provider’s online portal. Then, when the patient goes to check in at the hospital, surgical center, or provider’s office, we ask for a copy of their insurance card(s) and hand them a clipboard with a stack of papers to fill out, much of it covering the same information they already provided online or during scheduling or registration. If that weren’t frustrating enough, in most cases we ask them to do the same thing every time they’re seen and with every provider they see.
Identity is broken in healthcare. Patients should not have to fill out stacks of paperwork, providing the same information every time they see a new or existing provider.
A disjointed revenue cycle
From patient access to patient billing, our current revenue cycle was designed around claims adjudication and reimbursement, not the patient experience. Eligibility and coverage verification is an excellent example.
Providers and payers have a lot riding on having accurate eligibility and coverage information. Without accurate data, providers may not get paid, and payers may end up paying for services that were covered by another carrier.
Now that patients have greater responsibility for their healthcare costs, they, too, have a lot riding on eligibility and coverage information being accurate. If a service is denied because the provider didn’t have the correct information, patients can receive a bill for a service that should have been covered. With the growing burden of medical debt, this is a problem.
Today, more than a third of Americans have unpaid medical bills and half have medical debt that has gone into collections. When patients face medical debt, many often put off care. This is just another way that inefficient administrative processes negatively impact outcomes and the patient experience.
Data-sharing is broken in healthcare. Patients should not have to delay care or take on financial burdens because payers and providers can’t access accurate, complete eligibility and coverage information.
We aren’t speaking the same language
Provider organizations have invested millions in information and adjudication systems. As health systems grow organically and through M&A activity, those systems have become increasingly complex to manage. There may be a disparate mix of systems and bolt-on technologies, especially when a system has a hospital and physician groups. Getting these systems to connect and communicate within a single organization is a challenge, and even greater when communicating with other organizations. This makes providing a seamless patient experience difficult.
In a recent episode of The Spark, Ryan Howells, principal at Leavitt Partners and Program Manager at CARIN Alliance, talked about the importance of using non-proprietary, open standards like FHIR®, HL7®, and OpenID® to enable entities to communicate, collaborate, and transact. “These open standards allow us to move data similar to how it is moved in other, non-medical applications.” He reiterates that without open standards, the app economy that consumers have embraced and come to rely on wouldn't exist.
Until our industry adopts standards that enable us to speak the same language, organizations will continue to spend exorbitant resources managing many one-off connections, gateways, and file formats. Besides the excessive effort, having multiple connections with outside entities also introduces significant security risks.
Collaboration is broken in healthcare. Patients shouldn’t have to worry about their personal or medical information being sold on the dark web because providers and payers are unable to connect, collaborate, protect, and share information securely.
A new solution to enhance data-sharing and collaboration is poised to transform the patient experience
Recently, a large global healthcare system and a multi-state payer participated in a pilot program for a new type of collaboration solution that reinvents administrative processes and improves the patient experience.
The solution is a peer-to-peer digital network that enables payers and providers to access accurate, continuously updated, and complete insurance coverage information right in their source systems.
Each participant on the network receives their own provisioned cloud environment where they upload their patient/member coverage information. The solution converts all information into common FHIR standards, and a patient ID is created and matched to other network participants who provide services to the same patient/member. The solution then analyzes all instances of an individual’s coverage information for discrepancies. If found, participants are automatically notified. The updated information can be viewed on a portal or automatically posted into their EHRs.
Imagine the impact this type of collaboration solution can have on reducing issues with medical necessity, prior authorizations, denials, and surprise patient bills by giving all parties real-time access to information—no faxes, emails, or phone calls needed.
One of the solution’s most significant benefits is its ability to protect patient data. Because the data doesn’t need to be aggregated or sent to intermediaries like clearinghouses, it remains safely within the network and under the control of the data originator. Auditable records give complete insight into how, when, and with whom data was shared.
Changing paradigms
Joining Ryan Howells on The Spark podcast was Jason Sherwin, Senior Director of Healthcare Business Development at CLEAR. Jason emphasized that our goal in healthcare should be to “break down data silos that have been built up over the past 10 to 15 years, and really empower consumers, whether they be a patient or whether they be a provider, to be able to access, control, and share information to ultimately streamline the experience for all.”
Changing how we think about administrative processes and their impact on consumers is the first step to achieving this goal.
