MedCity Influencers, Health IT, Payers

From transactions to transformation: How to deliver on the patient-centric promise

We’ve been talking about improving patient satisfaction and creating a more patient-centric care experience for years. But we’ll never get there if we continue to be focused on transactional healthcare, which is where our efforts toward interoperability have traditionally been drawn.

Who doesn’t have a story about how navigating today’s healthcare system didn’t go well for you, a family member, or a friend?

Consider the patient with Type I diabetes who relocates to a new community. After finding a doctor who will take her insurance, she schedules an appointment. Upon arriving at the office, it was unclear how much she’d have to pay for the visit and labs, adding to the anxiety of seeing a new doctor. Additionally, the office said they hadn’t yet received a copy of her medical record from her previous doctor, even though it had been over a month since it was requested. The patient has to try to remember and relay years of medical history, past medications, previous tests and procedures, and her history of providers.

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Or consider the patient whose knee surgery had to be delayed for months due to issues between the provider and payer. The insurance company didn’t receive all the clinical details on the prior authorization request from the provider showing that less invasive and costly therapies have been used with no improvement. Because the insurance company rejected the prior authorization, the patient had to wait or work out a payment plan. All the while, the patient’s knee pain became so debilitating that he had to take medical leave. Had he been able to get the surgery sooner, he could have been back to work and on the road to recovery much faster.

These are just two of the numerous examples where administrative processes get in the way of a patient’s need for timely care. There are two common denominators in all of these situations:

  • First, communication and the sharing of data between the provider and payer is disjointed.
  • Second, the focus is on administrative processes and not on the patient.

How do we transition from being process focused to person focused?

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A Deep-dive Into Specialty Pharma

A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.

The answer is interoperability. It enables the secure, seamless exchange of patient data like medical records, eligibility information, and prior authorization. It can also result in better outcomes. Three out of four providers who participate in health information exchange (HIE) see improved quality of care, better practice efficiencies, and increased patient safety.

While adoption of HIE is growing, it’s not growing fast enough. Research shows that in 2019 more than one in three physicians still relied solely on fax (electronic or paper) or standard mail to share patient information with providers outside their organization. Just 34% engaged in bi-directional electronic exchange of patient information outside their organization. The problem is that the foundation of HIE is currently reliant on a one-to-one infrastructure, or data pipelines built within specific boundaries, and it’s still heavily transaction focused.

What we need is a one-to-many network without boundaries, where providers can access patient data with permission in real time through a single query. Instead of waiting for weeks to gain access to a patient’s medical history, providers could perform a simple query at a moment’s notice—during a patient visit, in an emergency department, or when seeing a patient who’s from across the country—giving them instant access to the information they need to make more timely, informed decisions about the patient’s care. THAT is how healthcare becomes patient centric.

The burden of distrust in healthcare

Our current healthcare infrastructure is built around the distrust between payers and providers. It’s completely understandable. Providers see how payer processes can impede care, create administrative burdens for clinicians, and impact patients. However, fraud, waste, and abuse cost payers billions each year. Today, they are using more sophisticated technology to try to identify potential claim issues that led to increasing claim denials for providers.

The distrust extends to patients as well, most of whom don’t trust the amount their provider tells them they will owe for their service. More and more, patients are refuting their provider’s upfront request for payment, preferring instead to wait to see what their insurance actually pays. This distrust can negatively impact the entire patient experience, even offsetting a positive clinical experience.

All of these issues can be overcome.

It’s time to flip the script

Creating a patient-centric healthcare ecosystem is going to require payers, providers, patients, and other stakeholders to think differently about how business is conducted. It needs to be about more than streamlining transactions, although that’s important. It needs to be about how data is shared and accessed on the patient’s behalf. It’s about enabling real-time access to all the information needed to provide the best care at any location at a moment’s notice. In other words, it’s about the patient.

A great place to begin is with a secure, decentralized, peer-to-peer network that allows for more effective, real-time communication, consensus, and collaboration between payers and providers, which enables a better, more timely care experience for the patient.

In such a network, every authorized participant has permissioned access to the same permissioned information while no single entity can control, modify, delete, or change the rules of how the network can be used. Because the network is blockchain enabled, it provides ultimate security in that there’s no longer a need to reconcile data. Each permissioned participant is the author of its own data instead of sending it to a third party (centralized); the data remains in the participant’s control (decentralized). With FHIR, data is standardized and ready to be accessed. This type of network will remove the friction that has plagued our healthcare system for far too long—friction that ends up as another barrier to care for the patient.

This new patient-centric network eliminates the need for providers to print, fax, email, or mail a copy of a patient’s medical record to another provider. In the case of the woman who relocated, her complete medical history would be discoverable in real time by her new provider. In the case of the man needing knee surgery, preconfigured pathways would remove the need for push/pull preauthorization transactions. Because the network is designed around data sharing, the data becomes fluid. In this case the patient’s provider can easily access the patient’s coverage information and preauthorization guidelines over the network, and then submit the request for approval at the same time.

The bottom line

We’ve been talking about improving patient satisfaction and creating a more patient-centric care experience for years. But we’ll never get there if we continue to be focused on transactional healthcare, which is where our efforts toward interoperability have traditionally been drawn.

Healthcare, at its core, is about providing timely access to high-quality care and everything we do should be directed toward this effort. Only when we achieve this goal will we truly transform the care experience.

Photo: CYCLONEPROJECT, Getty Images

Stuart Hanson is passionate about creating a better consumer healthcare experience and has joined Avaneer Health as CEO to build an inclusive network that ensures all stakeholders have equal access to comprehensive data when it’s needed most. Stuart previously served in leadership roles for healthcare solutions at JPMorgan Chase, Change Healthcare, Citi, and Fifth Third Bank. He has served as chair of the HIMSS Revenue Cycle Improvement Task Force. Stuart has a bachelor’s degree from University of Illinois and an MBA from University of Chicago Booth School of Business. Stuart is a dynamic, innovative leader committed to improving the healthcare ecosystem.