America ranks dead-last in health care efficiency compared with our peer countries, the Commonwealth Fund concluded in its study on how the U.S. health care system performs internationally.
Waste and inefficiency add costs to U.S. health care system. And health care costs rank highest on a new list of consumers’ worries found by the Monmouth Poll this week, well above jobs, housing, terrorism or immigration.
In the current American health reform debate, inefficiency and waste don’t get raised as top concerns. Consider that the U.S. spent $3.2 trillion on health care in 2015. As much as $300 billion of that money is wasted, and a big piece of that inefficiency is due to paper processes with which last century’s TV doctors Kildare, Welby, and perhaps even Hawkeye Pierce would have been familiar.
But this is the 21st century, and today is Feb. 9, 2017. Here is my personal story of health care paper and wasted costs to illustrate that this issue belongs to every U.S. health citizen.
On October 19, 2016, I went to the pharmacy in a suburban Philadelphia grocery store to get a flu shot. Before heading to the store, I checked with my health plan’s list of approved providers for immunizations, and that particular location was included.
I checked in with the pharmacy tech, who asked for my insurance card. When he clicked into the system for authorization, my coverage wasn’t available. The tech asked for assistance from the pharmacist, who double-checked the tech’s workflow and, sure enough, my health plan information wasn’t current in the computer system even though our premium for coverage had been paid.
After 15 minutes of the staff’s various computer clicks, I phoned my health plan’s third party administrator to inquire. In 10 minutes on the phone, I was counseled to “simply” pay for the flu shot and submit for reimbursement, which would be paid in full given that this was a covered preventive service in our health plan.
I got the shot, and handed a credit card to the tech who charged me $28.99 for the service.
Since that day, I have received six emails from the third party administrator concerning my reimbursement. She informed me that I would receive three (paper) checks to cover the $28.99.
I subsequently received two Explanations of Benefit forms from my health plan on October 31, 2016 and January 9, 2017. The first detailed the billed amount of $28.99, an allowed amount of $13.88, a coinsurance of $6.94, a “not covered” amount of $15.11, “what my plan paid” of $6.94, and “what I owed” amounting to $22.05. The second EOB indicated that of the $28.99 total flu shot cost, the plan paid $8.06.
So far, I have received a check for $6.94 (the “what my plan paid” amount) dated October 31, 2016, and a check for $8.06, dated January 9, 2017. I have been told, in one of the third party admin’s emails, that I should be receiving a third check in the amount of $13.99 from the grocery store pharmacy, but that check hasn’t yet arrived.
It’s now 121 days since I got my flu shot. I’ve calculated the real cost of that shot, and specifically the paper and workflows associated with the transaction and its aftermath: it’s at least $100. That accounts for the pharmacy workers’ time, the third part admin’s emails and follow-ups, and the insurance company’s EOBs and paper check cutting.
This direct cost calculation doesn’t include the patient’s (my) time-cost and aggravation that can lead to lower satisfaction and, potentially, plan and provider “flight.”
I am the shoemaker’s child with no shoes in this story. For nine years, I have been a member of the Advisory Council to the CAQH Index, which has been measuring the adoption of electronic, real-time transactions, away from paper-based processes, by health plans and health care providers.
The 2016 Index found continued migration to electronic transactions among health plans and providers, especially for submitting claims, verifying eligibility for the patient-member, inquiring into claim status, and paying for claims. Nevertheless, the use of manual transactions is not declining as rapidly as we would like, with phone calls still consuming significant time and money. This is happening, even though health plans are offering web portals and interactive voice response systems to replace manual processes.
“Our research for the Index shows that while progress has been steady, there are opportunities to encourage greater industry use of electronic transactions by reducing adoption barriers and sharing best practices,” observed Robin Thomashauer, Executive Director, CAQH. “Realizing the full potential of these transactions will require an ongoing commitment by all health care stakeholders, including health plans, providers, vendors and government.”
Each manual transaction costs health plans and health care providers about $3 more than the electronic transaction that could replace them. Since there were over 3 billion manual transactions between health plans and providers in 2015, moving to digital transactions represents a potential $9 billion savings for the U.S. health care system and its payors – which include consumers as we take on greater up-front financial risk in high-deductible health plans and health savings accounts.
My $100 flu shot was but one single transaction in the U.S. health care ecosystem that represents a much larger scenario of waste in American health care. That waste costs, in terms of money, time, and ultimately, the nation’s public and financial health.
We’ll be brainstorming the implications of the 2016 CAQH Index during a Tweetchat on Thursday, February 16th, at 2 pm ET, using the hashtag #CAQHchat.