Post-Apocalyptic Wellness Care

Post-apocalyptic life inwards American wellness care is a fantastic spider web log postal service on the ground of American wellness attention in addition to insurance. (HT Marginal Revolution)

Bottom line:

American wellness attention organizations tin no longer operate systematically, so participants are forced to deed inwards the communal mode, every bit if inwards the pre-modern world.

The formal systems of wellness attention are  broken nether [my interpretation, to follow] the weight of regulation. By "formal systems" I hateful the normal bureaucratic procedures past times which large organizations run in addition to interact: a laid of rules, forms, records, in addition to so forth. "Bureaucratic" hither is non a pejorative. Bureaucracy is what allows large organizations to work.

This isn't virtually engineering -- for centuries large organizations worked good using the engineering of paper, writing, forms, in addition to files. Electronic records but brand those structures piece of work to a greater extent than efficiently.

But when the rules in addition to formal systems grow immense, vague, contradictory, in addition to unworkable, human networks shape inwards their place. Then things hand entirely past times networks of personal connections, informal structures working but about the dead elephant inwards the room to acquire anything accomplished. The latter, at cracking inefficiency, of course. Large bureaucratic organizations, allowing people to cooperate anonymously, are vital to an advanced society.

Later inwards the post,

It’s similar 1 those post-apocalyptic scientific discipline fiction novels whose characters hunt wild boars with spears inwards the ruins of a modern city. Surrounded past times machines no 1 understands whatever longer, they have got reverted to primitive technology.

Except it’s inwards reverse. Hospitals tin nevertheless operate modern cloth technologies (like an MRI) but fine. It’s social technologies that have got broken downwards in addition to reverted to a medieval level.

Systematic social relationships involve formally-defined roles in addition to responsibilities. That is, “professionalism.” But across medical organizations, at that spot are none. Who do you lot telephone telephone at Anthem to discovery out if they’ll encompass an out-of-state SNF stay? No 1 knows.

To live specific, follow the writer through a detailed personal story. The story takes a while, in addition to it's 1 story, but the granularity of a story makes the instance vivid.

My woman raise [also with dementia] went into the infirmary a calendar month agone with severe hurting inwards her hip. (It’s nevertheless undiagnosed.) After 2 days, she was medically ready for discharge from the hospital: whatever the hurting was, it wasn’t 1 they could assist with. Instead, she should live sent to a “skilled nursing facility” (SNF) where she’d acquire “physical therapy,” i.e. leg exercises.

Most wellness attention policy ground is virtually who volition pay, every bit if the goodness to live determined, handling for a specific condition, were known in addition to good priced. Of course of written report that's non fifty-fifty vaguely true. As nosotros all know from experience, diagnosis, running from Dr. to Dr. in addition to specialist to specialist, is a catastrophe today. It's frequently impossible when buying insurance to figure out if a given Dr. is inwards network, or fifty-fifty when getting attention whether it volition live covered.

But this story is virtually something much simpler than the commons handling snafus:

For a SNF to take away hold to have got her, they had to acquire confirmation from an insurance fellowship that insurance would encompass her stay. She has 2 kinds of wellness insurance, Medicare addition coverage through a individual insurer (Anthem). Which would encompass her? Or both, or neither?

This seems unproblematic enough, no?

SNFs have got admissions officers, whose full-time chore is to response this question. Two dissimilar SNFs started working on the problem. I talked with the admissions people every day. Both claimed to live working on it more-or-less full-time. The infirmary wanted to gratuitous upward my mother’s bed, so their insurance individual was also working on it. 

Days passed. The infirmary Dr. on rounds said “Well, this is typical, particularly with Anthem. It’s costing them several G dollars a solar daytime to hold her here, versus a few hundred dollars a solar daytime inwards a SNF, but it mightiness have got a calendar 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 in addition to Medicare were confused virtually their relationship... Medicare believed that my woman raise (who retired inwards 1997) is employed in addition to hence ineligible. Her Anthem coverage is through her quondam employer. 

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

H5N1 calendar week later, I called Medicare to verify that it worked. The surprisingly competent client service individual looked upward my mother’s information in addition to said: “This is genuinely weird… I don’t know what’s going on… at that spot was a tape that said Anthem is primary. And in addition to so on Nov 16th, there’s a banking concern annotation that said it’s deleted, in addition to Medicare is primary. But in addition to so there’s an update on the 18th that says Anthem is primary. But plainly since your woman raise is 84 she’s non employed, so Medicare should live primary… I’ll delete the tape again…” 

After 3 days of trying, 1 of the SNFs gave up. I talked to the admissions dude there. I’ll telephone telephone him Paul. He was smart in addition to friendly, in addition to he was willing to explain: 

"My full-time chore for 10 years has been agreement how to acquire insurance to pay us, in addition to I have got no sentiment how the scheme works. Even if I somehow learned how it works, it changes completely every year, [my emphasis] in addition to I would have got to get-go over. But at most of the insurance companies I know people who tin sometimes brand things happen, so I telephone telephone them up, in addition to and so they travail to figure out how it works. But Anthem… I spent hours in addition to hours on hold, in addition to inwards telephone trees, getting transferred from 1 subdivision to another, in addition to eventually dorsum to where I started. The most clueful-sounding individual I could discovery sent me to a spider web site that but says ‘This computer program is non implemented yet.’ Does ‘program’ hateful software, or does it hateful some projection they haven’t got going?"

In sum,

at to the lowest degree vii experts spent roughly 10 full-time days trying to discovery out a basic fact virtually my mother’s insurance, in addition to endure failed

This isn't virtually health, where logic ordinarily departs inwards wellness attention discussions. It's virtually money, something that large bureaucratic individual organizations ordinarily handgrip well. You don't demand to telephone telephone the banking concern a hundred times to discovery out your occupation organisation human relationship balance.  Notice that this is a struggle betwixt a large regulated insurance fellowship in addition to Medicare, the authorities program, non a pathology of gratuitous markets.

Notice also the "changes completely every year." One affair large bureaucratic organizations do non do is to alter the rules completely every year! People demand to acquire to know the rules, in addition to to know the channels past times which an arrangement works. This does non hand if the rules alter every year.

But why are rules changing every year? Life insurance, motorcar insurance, dwelling insurance rules don't alter every year! This is an artifact of our electrical current regulation, particularly the ACA, which has destroyed long-term insurance. What policies are offered, how much they cost, who is inwards in addition to who is out of network -- all of that changes every year, in addition to companies demand to renegotiate the whole bundle with ground regulators every year. The marketplace does non hit this pathology.

Hospitals are bad places that brand you lot ill; you lot don’t desire to pass whatever to a greater extent than fourth dimension at that spot than you lot have got to. On solar daytime six, I said “if she doesn’t move to a SNF today, I’m taking her home—the take away a opportunity of her dying at that spot seems less instantly than the take away a opportunity of her dying here.” That got results: the other SNF agreed to have got her “on spec.” Their admissions individual was reasonably confident that either Anthem or Medicare would pay, fifty-fifty 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 lot desire me to do virtually that? We demand you lot to telephone telephone the infirmary in addition to enquire them to fax us the records. “Fax”? Why non ship clay tablets inwards wicker baskets on the dorsum of a donkey?

The venerable fax machine. Again, the writer is goodness on story in addition to less on why. Why must medical records live faxed around? Why can't infirmary 1 acquire records from infirmary 2? The response at that spot is clear every bit a bell: HIPPA, the extensive privacy regulations surrounding medical records. 

Their effect is ludicrous beyond fax machines. We long agone should have got had medical records stored inwards our Iphones or fitbits, in addition to have got them with us where needed. This isn't a engineering problem, it's a legal problem. 

It's most hilarious every fourth dimension I move to a infirmary or doctor's office. You've been at that spot too. You sit down downwards with pen in addition to paper, in addition to you lot are asked to fill upward inwards your medical history. 

Are you lot kidding? I'm 60. My medical history, that I tin recall of it mightiness get-go with "Chicken pox, historic menstruation 7. Asthma, historic menstruation 10. Broken leg, Age 12." in addition to move on similar that for page after page. I don't bother of course of written report -- nobody does. More hilarious, one-half of this materials was treated at the really infirmary where I am instantly sitting. The sentiment must have got occurred to many of you: If my retentiveness on this shape is of import -- if anything life saving is of import to discover here, why inwards the ground are you lot trusting my retentiveness on this? Does a bank, when you lot apply for an account, enquire "write downwards the history of every cheque you've received or paid." 

The writer starts to sniff where the problem lies: 

I was trying to acquire my woman raise into a SNF—but all I could do was verbalize to Paul, who couldn’t say yes or no. It wasn’t his fault. He was trying to verbalize 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 inwards what situation. 

Actually, that's off past times at to the lowest degree an monastic say of magnitude. The ACA itself is longer than that. Between ACA, HIPAA, subsidiary HHS rules, ground in addition to local regulations, in addition to interpretations of those, add together at to the lowest degree some other zero

And the rules are vague in addition to conflicting in addition to alter constantly, in addition to who tin read 1600 pages of rules anyway? So eventually someone has to brand upward a yes-or-no response on the ground of what seems more-or-less reasonable. Whoever it is could acquire blamed if someone to a higher identify afterward decides that was “wrong” based on their interpretation of the rules, so it’s improve to top the buck.

Are the confused rules Anthem’s fault? I imagine that the 1600 pages travail to reconcile federal, state, in addition to local legislation, addition the rules of 3 federal regulatory agencies, nine ground agencies, in addition to 15 local agencies. All those are vague in addition to conflicting in addition to constantly changing, but Anthem’s rule-writing subdivision does their best. They telephone telephone the agencies to travail to discovery out what the regulations are supposed to mean, in addition to they pass hours on hold, are transferred from 1 official to some other in addition to back, in addition to eventually acquire directed to a .gov spider web site that says “program non implemented yet.” Then they brand something up, in addition to promise that when the authorities sues Anthem, they don’t acquire blamed for it personally.

I imagine people working inwards legislative offices in addition to regulatory agencies discovery themselves inwards a similar position.

In this maze, fifty-fifty competent people with goodness intentions cannot deed systematically. Their piece of work depends on coordinating with other institutions that have got no systematic interface.

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

Back to the post-apocalyptic vision; people standing but about alongside aqueducts that no longer piece of work in addition to they don't know how to fix:

Working inwards a medical business office is similar living inwards a pre-modern town. It’s all virtually knowing someone who knows someone who knows someone who tin acquire something done. Several times, I’ve taken my woman raise to a Dr. who said something like: “She needs lymphedema treatment, in addition to the entirely lymphedema clinic but about hither is booked months inwards advance, but I know someone there, in addition to I think I tin acquire her inwards adjacent week.” 

I know my left of amount friends are chomping at the fleck hither -- "single payer volition solve it all. The occupation hither is a pointless struggle virtually who volition pay." But that is a fleck similar people who trash their ain houses, which endure burn, in addition to and so demand the authorities create them novel ones because nosotros all saw how awful the houses were.  Single payer systems also frequently chop-chop devolve into dysfunctional bureaucracies, in addition to getting attention depends on networks of personal connections to piece of work the system.

The writer seems to think that wellness insurance is but the vanguard of a tendency taking over our lodge inwards general:

I suspect increasing “patchiness” of systems may live typical of our post-systematic atomized era. Understanding the medical instance may assist predict the texture of cultural in addition to social life every bit atomization proceeds.

and

Health attention is 1 leading border of a full general breakdown inwards systematicity—while, at the same time, employing sophisticated systematic technologies. 

Communal-mode interpersonal skills may move increasingly of import to life success—not less, every bit techies hope.

I disagree, in addition to the spider web log postal service shows why. The writer rightly notices that wellness attention is pathological, in addition to that other, private, large organizations piece of work well.

To ship a bundle past times FedEx, you lot don’t demand to telephone telephone someone who knows someone who knows someone. You move to a spider web site, pose inwards some numbers, it gives you lot dorsum some numbers, you lot pose them on the envelope, driblet it inwards a box, in addition to it appears at a farmhouse on an isle inwards Lapland the adjacent day.

If Amazon sends you lot the incorrect type of cable adapter, you lot don’t have got to telephone telephone them upward in addition to travail to deed miserable in addition to virtuous inwards monastic say to convince someone that you lot demand in addition to deserve a refund because your poor woman raise is so ill. You move to a spider web site in addition to force a button.

Many other large systems of bureaucracies nevertheless are functional. Banks in addition to airlines work. If the websites fails, you lot tin telephone telephone in addition to acquire things fixed. You don't demand a fixer who knows the special telephone bring out of a guy or gal who tin create upward one's hear if your flying alter is reasonable. Facebook, Google, Uber, in addition to so forth operate genuinely with no people -- you lot can't telephone telephone anyone, in addition to don't demand to. The interface is unproblematic in addition to excellent.

Even much authorities continues to work. The DMV plant every bit a bureaucracy. I had to register an imported trailer recently. The lady at the Redwood City DMV genuinely knew which channels to have got in addition to which pieces of newspaper needed to live filled out, or at to the lowest degree could chop-chop access that information. Yes, it was slow, yes, it was almost charming to take in a bureaucracy surgery with 1970s engineering with stacks of physical pieces of newspaper going around. But it works, I didn't demand a fixer.

Where are large bureaucracies falling apart inwards this way, that webs of personal connections are necessary to hold things going, in addition to where are they non falling apart? Health insurance is the poster child, but the highly regulated or authorities organizations stand upward out. Taxes. Estates. Real estate zoning permitting is headed that way. Large businesses dealing with regulatory agencies all have got to piece of work this agency to a greater extent than in addition to more. Increasingly, retirement finance is heading this way. I had a lovely conversation at a B in addition to B late with a really overnice adult woman whose chore it is to assist teachers with retirement options. Many have got authorities loans. She started to explicate the myriad programs to assist them with complex filing requirements, diverse forgiveness rules in addition to so on. H5N1 finance professor, me, was completely lost past times the minute loving cup of coffee. Public schoolhouse teachers facing retirement with some pupil debt instantly demand a fixer too.

The blog's bottom line:

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

Perhaps the marketplace volition respond, with a furnish of professional person fixers, similar my breakfast companion. For rich people, it's concierge medicine, where the Dr. genuinely serves to navigate the same mess of wellness care, non insurance.