Post-Apocalyptic Health Care

Post-apocalyptic life in American health care is a fantastic blog post on the state of American health care and insurance. (HT Marginal Revolution)

Bottom line:

American health care organizations can no longer operate systematically, so participants are forced to act in the communal mode, as if in the pre-modern world.

The formal systems of health care are  broken under [my interpretation, to follow] the weight of regulation. By "formal systems" I mean the normal bureaucratic procedures by which large organizations run and interact: a set of rules, forms, records, and so forth. "Bureaucratic" here is not a pejorative. Bureaucracy is what allows large organizations to work.

This isn't about technology -- for centuries large organizations worked well using the technology of paper, writing, forms, and files. Electronic records just make those structures work more efficiently.

But when the rules and formal systems grow immense, vague, contradictory, and unworkable, human networks form in their place. Then things happen only by networks of personal connections, informal structures working around the dead elephant in the room to get anything accomplished. The latter, at great inefficiency, of course. Large bureaucratic organizations, allowing people to cooperate anonymously, are vital to an advanced society.

Later in the post,

It’s like one those post-apocalyptic science fiction novels whose characters hunt wild boars with spears in the ruins of a modern city. Surrounded by machines no one understands any longer, they have reverted to primitive technology.

Except it’s in reverse. Hospitals can still operate modern material technologies (like an MRI) just fine. It’s social technologies that have broken down and reverted to a medieval level.

Systematic social relationships involve formally-defined roles and responsibilities. That is, “professionalism.” But across medical organizations, there are none. Who do you call at Anthem to find out if they’ll cover an out-of-state SNF stay? No one knows.

To be specific, follow the author through a detailed personal story. The story takes a while, and it's one story, but the granularity of a story makes the case vivid.

My mother [also with dementia] went into the hospital a month ago with severe pain in her hip. (It’s still undiagnosed.) After two days, she was medically ready for discharge from the hospital: whatever the pain was, it wasn’t one they could help with. Instead, she should be sent to a “skilled nursing facility” (SNF) where she’d get “physical therapy,” i.e. leg exercises.

Most health care policy debate is about who will pay, as if the good to be determined, treatment for a specific condition, were known and well priced. Of course that's not even vaguely true. As we all know from experience, diagnosis, running from doctor to doctor and specialist to specialist, is a catastrophe today. It's often impossible when buying insurance to figure out if a given doctor is in network, or even when getting care whether it will be covered.

But this story is about something much simpler than the usual treatment snafus:

For a SNF to agree to take her, they had to get confirmation from an insurance company that insurance would cover her stay. She has two kinds of health insurance, Medicare plus coverage through a private insurer (Anthem). Which would cover her? Or both, or neither?

This seems simple enough, no?

SNFs have admissions officers, whose full-time job is to answer this question. Two different SNFs started working on the problem. I talked with the admissions people every day. Both claimed to be working on it more-or-less full-time. The hospital wanted to free up my mother’s bed, so their insurance person was also working on it. 

Days passed. The hospital doctor on rounds said “Well, this is typical, especially with Anthem. It’s costing them several thousand dollars a day to keep her here, versus a few hundred dollars a day in a SNF, but it might take a week for them to figure out which local SNF they cover. Don’t worry, they’ll sort it out eventually.” 

Meanwhile, I learned that Anthem and Medicare were confused about their relationship... Medicare believed that my mother (who retired in 1997) is employed and therefore ineligible. Her Anthem coverage is through her former employer. 

I talked with her ex-employer’s benefits person (whose full-time job is understanding insurance, pretty much). She looked into it and said she couldn’t understand what was going on. She called the company’s outside insurance consultant. He couldn’t understand what was going on. He called people he knew at Medicare and Anthem. He said that they couldn’t understand it either, but that multiple people in both organizations were working on straightening it out. 

A week later, I called Medicare to verify that it worked. The surprisingly competent customer service person looked up my mother’s info and said: “This is really weird… I don’t know what’s going on… there was a record that said Anthem is primary. And then on November 16th, there’s a note that said it’s deleted, and Medicare is primary. But then there’s an update on the 18th that says Anthem is primary. But obviously since your mother is 84 she’s not employed, so Medicare should be primary… I’ll delete the record again…” 

After three days of trying, one of the SNFs gave up. I talked to the admissions dude there. I’ll call him Paul. He was smart and friendly, and he was willing to explain: 

"My full-time job for ten years has been understanding how to get insurance to pay us, and I have no idea how the system works. Even if I somehow learned how it works, it changes completely every year, [my emphasis] and I would have to start over. But at most of the insurance companies I know people who can sometimes make things happen, so I call them up, and then they try to figure out how it works. But Anthem… I spent hours and hours on hold, and in phone trees, getting transferred from one department to another, and eventually back to where I started. The most clueful-sounding person I could find sent me to a web site that just says ‘This program is not implemented yet.’ Does ‘program’ mean software, or does it mean some project they haven’t got going?"

In sum,

at least seven experts spent roughly ten full-time days trying to find out a basic fact about my mother’s insurance, and finally failed

This isn't about health, where logic usually departs in health care discussions. It's about money, something that large bureaucratic private organizations usually handle well. You don't need to call the bank a hundred times to find out your account balance.  Notice that this is a fight between a large regulated insurance company and Medicare, the government program, not a pathology of free markets.

Notice also the "changes completely every year." One thing large bureaucratic organizations do not do is to change the rules completely every year! People need to get to know the rules, and to know the channels by which an organization works. This does not happen if the rules change every year.

But why are rules changing every year? Life insurance, car insurance, home insurance rules don't change every year! This is an artifact of our current regulation, especially the ACA, which has destroyed long-term insurance. What policies are offered, how much they cost, who is in and who is out of network -- all of that changes every year, and companies need to renegotiate the whole package with state regulators every year. The market does not produce this pathology.

Hospitals are bad places that make you ill; you don’t want to spend any more time there than you have to. On day six, I said “if she doesn’t go to a SNF today, I’m taking her home—the risk of her dying there seems less now than the risk of her dying here.” That got results: the other SNF agreed to take her “on spec.” Their admissions person was reasonably confident that either Anthem or Medicare would pay, even though neither was willing to say either yes or no ahead of time. 

The SNF called me to tell me they needed my mother’s records from the hospital. Well, what do you want me to do about that? We need you to call the hospital and ask them to fax us the records. “Fax”? Why not send clay tablets in wicker baskets on the back of a donkey?

The venerable fax machine. Again, the author is good on story and less on why. Why must medical records be faxed around? Why can't hospital 1 get records from hospital 2? The answer there is clear as a bell: HIPPA, the extensive privacy regulations surrounding medical records. 

Their result is ludicrous beyond fax machines. We long ago should have had medical records stored in our Iphones or fitbits, and take them with us where needed. This isn't a technology problem, it's a legal problem. 

It's most hilarious every time I go to a hospital or doctor's office. You've been there too. You sit down with pen and paper, and you are asked to fill in your medical history. 

Are you kidding? I'm 60. My medical history, that I can remember of it might start with "Chicken pox, age 7. Asthma, age 10. Broken leg, Age 12." and go on like that for page after page. I don't bother of course -- nobody does. More hilarious, half of this stuff was treated at the very hospital where I am now sitting. The thought must have occurred to many of you: If my memory on this form is important -- if anything life saving is important to disclose here, why in the world are you trusting my memory on this? Does a bank, when you apply for an account, ask "write down the history of every check you've received or paid." 

The author starts to sniff where the trouble lies: 

I was trying to get my mother into a SNF—but all I could do was talk to Paul, who couldn’t say yes or no. It wasn’t his fault. He was trying to talk to people at Anthem, who couldn’t say yes or no. Was that their fault?

Just speculating, I imagine they are supposed to apply 1600 pages of rules for what’s covered in what situation. 

Actually, that's off by at least an order of magnitude. The ACA itself is longer than that. Between ACA, HIPAA, subsidiary HHS rules, state and local regulations, and interpretations of those, add at least another zero

And the rules are vague and conflicting and change constantly, and who can read 1600 pages of rules anyway? So eventually someone has to make up a yes-or-no answer on the basis of what seems more-or-less reasonable. Whoever it is could get blamed if someone higher up later decides that was “wrong” based on their interpretation of the rules, so it’s better to pass the buck.

Are the confused rules Anthem’s fault? I imagine that the 1600 pages try to reconcile federal, state, and local legislation, plus the rules of three federal regulatory agencies, nine state agencies, and fifteen local agencies. All those are vague and conflicting and constantly changing, but Anthem’s rule-writing department does their best. They call the agencies to try to find out what the regulations are supposed to mean, and they spend hours on hold, are transferred from one official to another and back, and eventually get directed to a .gov web site that says “program not implemented yet.” Then they make something up, and hope that when the government sues Anthem, they don’t get blamed for it personally.

I imagine people working in legislative offices and regulatory agencies find themselves in a similar position.

In this maze, even competent people with good intentions cannot act systematically. Their work depends on coordinating with other institutions that have no systematic interface.

I don't think it's really the "interface" that is broken. The internal workings are so broken that no interface is possible.

Back to the post-apocalyptic vision; people standing around among aqueducts that no longer work and they don't know how to fix:

Working in a medical office is like living in a pre-modern town. It’s all about knowing someone who knows someone who knows someone who can get something done. Several times, I’ve taken my mother to a doctor who said something like: “She needs lymphedema treatment, and the only lymphedema clinic around here is booked months in advance, but I know someone there, and I think I can get her in next week.” 

I know my left of center friends are chomping at the bit here -- "single payer will solve it all. The problem here is a pointless fight about who will pay." But that is a bit like people who trash their own houses, which finally burn, and then demand the government build them new ones because we all saw how awful the houses were.  Single payer systems also often quickly devolve into dysfunctional bureaucracies, and getting care depends on networks of personal connections to work the system.

The author seems to think that health insurance is just the vanguard of a trend taking over our society in general:

I suspect increasing “patchiness” of systems may be typical of our post-systematic atomized era. Understanding the medical case may help predict the texture of cultural and social life as atomization proceeds.

and

Health care is one leading edge of a general breakdown in systematicity—while, at the same time, employing sophisticated systematic technologies. 

Communal-mode interpersonal skills may become increasingly important to life success—not less, as techies hope.

I disagree, and the blog post shows why. The author rightly notices that health care is pathological, and that other, private, large organizations work well.

To ship a package by FedEx, you don’t need to call someone who knows someone who knows someone. You go to a web site, put in some numbers, it gives you back some numbers, you put them on the envelope, drop it in a box, and it appears at a farmhouse on an island in Lapland the next day.

If Amazon sends you the wrong type of cable adapter, you don’t have to call them up and try to act pathetic and virtuous in order to convince someone that you need and deserve a refund because your poor mother is so ill. You go to a web site and push a button.

Many other large systems of bureaucracies still are functional. Banks and airlines work. If the websites fails, you can call and get things fixed. You don't need a fixer who knows the special phone number of a guy or gal who can decide if your flight change is reasonable. Facebook, Google, Uber, and so forth operate really with no people -- you can't call anyone, and don't need to. The interface is simple and excellent.

Even much government continues to work. The DMV works as a bureaucracy. I had to register an imported trailer recently. The lady at the Redwood City DMV actually knew which channels to take and which pieces of paper needed to be filled out, or at least could quickly access that information. Yes, it was slow, yes, it was almost charming to visit a bureaucracy functioning with 1970s technology with stacks of physical pieces of paper going around. But it works, I didn't need a fixer.

Where are large bureaucracies falling apart in this way, that webs of personal connections are necessary to keep things going, and where are they not falling apart? Health insurance is the poster child, but the highly regulated or government organizations stand out. Taxes. Estates. Real estate zoning permitting is headed that way. Large businesses dealing with regulatory agencies all have to work this way more and more. Increasingly, retirement finance is heading this way. I had a lovely conversation at a B and B recently with a very nice woman whose job it is to help teachers with retirement options. Many have government loans. She started to explain the myriad programs to help them with complex filing requirements, various forgiveness rules and so on. A finance professor, me, was completely lost by the second cup of coffee. Public school teachers facing retirement with some student debt now need a fixer too.

The blog's bottom line:

For complex health care problems, I recommend hiring a consultant to provide administrative (not medical!) guidance.

Perhaps the market will respond, with a supply of professional fixers, like my breakfast companion. For rich people, it's concierge medicine, where the doctor really serves to navigate the same mess of health care, not insurance.