Achieving health care’s best future means getting fundamentals correct now

Achieving health care’s best future means getting fundamentals correct now
© Getty Images

George Orwell wrote, “To see what is in front of one’s nose needs a constant struggle.” This is health care’s problem.

We have spent — and will continue to spend — billions of dollars developing, buying and marketing state-of-the-art technology designed to create care that is transparent, cost-effective and patient-centered. However, in our pursuit of the future, we’re overlooking foundational elements that make the health-care system patients deserve more difficult to achieve.

We can sell a compelling vision of a harmonized and connected tomorrow, but many doctors can’t determine today if the patient walking through their door is authorized to receive care.


Inefficient manual authorization processes are a primary cause of uncompensated care and cost providers almost a half-billion dollars annually, according to the latest CAQH Index report.

We throw around terms like “moonshot” and “disruption,” but can’t reliably tell a health plan consumer the location of a doctor’s office, if they are taking new patients or even if their providers are among the living. The Centers For Medicare and Medicaid Services (CMS) has reported in each of the last two years that that nearly half of Medicare Advantage physician directories contain material inaccuracies.

We’ve legislated that patients have more “skin in the game” when it comes to shouldering the cost of care, but price transparency is far from assured. In a 2016 survey by the Kaiser Family Foundation and the New York Times, patients cited unexpected claims denials, unknowingly visiting an out-of-network provider, and high deductibles as primary reasons behind their inability to pay for health-care services.

In my area of health care — creating transparent and efficient information exchange between health plans and physicians — laws in need to updating, like HIPAA, can prevent us from building, linking and sharing complete health records with health plans, providers and patients.

Admittedly, this stuff is prosaic. Yet achieving health care’s future is impossible without first solving the foundational problems rooted in our present moment. This is where our focus should be, but for the most part, it isn’t. For example, there is a high demand to share real-time data securely among payers, providers and patients. However, the quality and quantity of that data, including the speed with which it can be accessed by the appropriate stakeholders, is handcuffed by outdated organizational silos, inefficient manual processes and legislation in need of modernization.

Unfortunately, health care has spurred the growth of an entire cottage industry wholly dedicated to these enduring inefficiencies. Think about that for a moment; there are companies whose businesses are built and today flourish to support a broken system. That these businesses are necessary — much less thriving — points to severe and systemic problems.

Creating a more solid foundation for health-care’s building blocks requires several key ingredients: widespread adoption of automation; more efficient channels for sharing and maintaining health-care information; and modernization of laws governing health-care data access and sharing.

There are “green shoots” in each of these areas. For example, authorizations and other critical transactions are expected to continue to migrate, albeit slowly, to electronic automation. By automating the process of getting approval for these services, providers can retrieve information about a limitless number of claims at once, from multiple payers.

Providers are also getting savvier about patient financial health. Health-care price transparency is a laudable concept. Patients want it because they are contributing a larger share of the cost of care each year. The stumbling block for providers is that accurate pricing of health-care services is nearly nonexistent. Real-time adjudication and point-of-service collections with tangible and effective follow-up strategies are essential in today’s health-care market.

On the payer side, many health plans still store provider data on legacy systems in multiple, disconnected databases. As business requirements have evolved, insurance organizations have implemented incremental stop-gap measures to address data limitations, but these don’t address the core challenge: the lack of a single source of truth.

At the policy level, laws such as HIPAA, which was created in 1996, should be modernized to suit today’s technology and data challenges. For example, HIPAA currently limits how clearinghouses can share data by treating them as Business Associates (despite their status as Covered Entities), which requires them to execute data-use agreements with plans and providers. These added layers of bureaucracy impede patients’ timely and electronic access to their health-care information and the use of that information to enhance treatment, improve outcomes and manage health across populations.

We may be moving fast and breaking down barriers at industry trade shows and conferences, but in the real world we are missing the trees for the forest. Realizing tomorrow’s vision of a more efficient and patient-centric health-care system demands that we get the fundamentals right today.

Russ Thomas is CEO of Availity. Availity is a health-care information company that facilitates more than 10 million clinical, administrative and financial transactions each day among doctors, health plans and patients. The company also develops solutions to manage and optimize the hospital revenue cycle. This includes claims management and patient access.