Fixing Healthcare, Part One

Three ideas to fix healthcare could provide industry efficiencies.

An article that appeared in the July/August 2021 issue of BC Advantage got me thinking about some of the bureaucratic, redundant, labor-intensive, wasteful, and costly things that we do in healthcare – and how much more efficient we could be without them. Dave Jakielo, past president of the Healthcare Business and Management Association, shared three ideas to “fix healthcare.” In my opinion, the suggestions he offered would provide some industry efficiencies:

1. 1. There should be a mandatory fee schedule that applies the same price for every CPT® code by every payer, with an adjustment allowed for geographic differences.
   2. Payer-provider enrollment activities should be replaced by Medicare- approved provider status.
   3. We should eliminate the requirement for individual state licensures.

I agree that there would be numerous advantages to a mandatory fee schedule that applies the same price for every CPT code for every payer. This approach would:

• Eliminate the need for organization contract management staff and systems that manage the multiple fee schedules of the various payers;
• Reduce the need for payer-provider relations staff and simplify payer systems, since only one fee schedule would need to be managed;
• Significantly reduce the payment validation challenges in our billing departments; and
• Nullify, to a great extent, the battles about and need for “price transparency” and posting prices.

Like DRG and APC payments, this also requires the healthcare organization to effectively use its resources to get the services done within the pricing parameters, thus promoting competition and emphasizing customer service and quality. Additionally, it may adjust the profits of dominant marker payers that chisel down the rates they pay providers – because they wield the big stick.

As noted, Dave’s second suggestion was to abolish payer provider enrollment. Almost every third-party payer requires those who wish to be participating providers to enroll and complete an extensive credentialling application. He suggests that if the provider has enrolled in Medicare and has an NPI, that should be all that is required.

I also like the idea to abolish payer-required provider enrollment processes, for several reasons:

• It’s costly (to the payer and the provider), and if not done in timely fashion, pauses the ability of the provider to deliver services to patients and delays the rollout of a network of providers to a payer’s membership.
• If it’s replaced by Medicare provider status, it would encourage more providers to participate in Medicare. That point helps patients avoid having to pay for the claim and then seek reimbursement from their payer.
• If payers think they need some documentation to clutter their files, they could access the National Practitioner Data Bank for a file and ask for a copy of the credentials file from any healthcare institution that has admitted the provider to its membership and credentialed the provider accordingly.
• I’m not supporting the abolishment of the credentialing efforts of healthcare facilities. There’s still too much of a chance for a blind eye to be turned. I’d like to see the healthcare institutions become more stringent on their credentialing reviews than have the unnecessary efforts of provider enrollment activities on the backs of those institutions for their employed physicians (or on the backs of the practice staff for non-employed physicians). My recommendations are to have the physicians seeing patients, rather than completing redundant paperwork.

The elimination of state licensure in place of some type of national licensure eliminates the complex jigsaw puzzle of requirements. It’s so simple! Isn’t an MD an MD? Isn’t a pathologist a pathologist? Does the fact that they practice in Minneapolis any different from practicing in Memphis? There are other benefits, too:

• Eliminating the state barriers may allow some underserved border communities to have access to the clinical talent they have needed.
• It reduces the need for states to spend money on managing the licensure effort (although it will cut the state out of any fees they charge the providers). However, I think there should be a simple registration process for every provider in the state that would include their name, credentials, specialty (or specialties), and business address (or addresses).
• We may need to do a side-by-side comparison and establish the national standard. Then, getting it through the Centers for Medicare & Medicaid Services (CMS) will be another challenge.

This Biden Administration wants to tackle big business. Insurance companies ARE big business. Let’s push the Administration to simplify the administrative side of medicine so that our physicians can do what they were trained to do: treat patients.

Thanks to Dave for his article in BC Advantage Magazine.

I think there are numerous other examples of superfluous expenditures of time and resources that we can eliminate and allow healthcare providers get back to basics – like focusing on outcomes, quality, and customer service. 

[1] Jakielo, D. “Fixes for Healthcare: Part One.” BC Advantage Magazine. July/August 2021. P. 44-45. www.billing-coding.com

Programming Note: Listen to Rose Dunn report this story live today during Talk Ten Tuesdays, 10 Eastern.