Repairing the US Healthcare System

Step 1, Get rid of, or significantly reduce the waste, through judicial use of technology.

That's just my insight in working in healtcare technology during the past 7 years. I am not certain of the solutions that can exist the policy side of the issue, however, making good use of our current technologies can significantly remove much of the waste that currently exists throughout the delivery and payment systems in the US healthcare industry.

I stumbled upon a blog (can't remember how) dealing with how to fix our healthcare system from more of a pragmatic and policy perspective. It is written by Stanley Feld, M.D., FACP, MACE, where he provides some interesting approaches and thought into how the system can be fixed.

There is an interesting suggestion, made almost in an off-the-cuff manner, that seemed to jump out as I read through a posting of his.

Claims adjudicated at point of service should be as simple as it is during commercial transactions.

I love the idea of comparing/constrasting a financial transaction with a medical transaction. Granted, the rules of validating (e.g. adjudication) a medical transaction are a bit more complicated than a financial transaction (e.g. credit card swipe), there is still enough similiarities to borrow from some of the existing solutions and uses of technologies.

For example, instead of checking for account status (Is the account open? Is the credit balance high enough to take the pending charge without going over? In the case of a debit transaction, is the PIN correct?) you can check things that make since for the claim in question. There is already plenty of real time eligibility capabilities already in place with many point of service systems.

Let's just take that a step further. Why not pull down more of the ajudication rules and wrap them up either in the same eligibility transaction or in a similiar real time check?

I know that there are a lot of people who are smarter than me working on this problem as I would imagine there is quite a bit of money to be made in any solution that can trim the fat of the healthcare system. Heck, I currently work at a company who's entire business model is just finding the overpaid or fraudulent claim submissions and then collect the overpaid funds for the Payer -- and all this is AFTER the adjudication process.

So I know there is a lot of fat to be trimmed, and as such it has attracted a number of really smart people to trim that fat for financial gain. I am sure someone has already thought through this point of service type solution and if it isn't been done already, I wonder what the challenges are in preventing that group or person from moving forward.

I'll definately chalk this one up as warranting a little more research on my part.

Another potential solution is something that is already being done is Israel by one of the nationally funded HMO's, Clalit Health Services. I had the opportunity some months ago to speak with some of the folks at Clalit that implemented the solution that is discussed in the Microsoft case study and found it interesting that this insurance company's solution saved quite a bit of money while at the same time increased the quality of health of their insured.

They did this by leveraging predictive modeling that examined the entire population of claim submissions and was able to determine predictive scores of the liklihood that patient A would contract conditions B and D because of their current claim history thus far.

Clalit then alerts the primary care physician with a list of patients that this predictive modeling thinks needs closer attention based on the patterns of their ailments so far so that the physician can provide care sooner, which in many cases ends up being much cheaper.

There are a host of issues that would have to be solved in order to make that same solution work here in the US where the market is much more segmented -- we don't have a national healthcare system where patients can easily be uniquely identified, for one. However, I believe there is great potential in this model that Clalit has so innovatively implemented.

Tags: healthcare, healthcare system, repairing the healthcare system, clalit, predictive modeling, fix healthcare, health