How We’re Sick Now

The outbreak of COVID-19 has upended our standard contract with crisis management by scattering the notion that medical crises of the sort we’re slogging through now are tragedies that occur elsewhere. We understood our timeless role as a nation to be empathetic observers, not participants, whose primary task was delivering medical expertise to situations abroad. But then we unwittingly entered a pandemic and went to the outskirts of town with our indecisive implements to tap and check on the state of the levees, which are not to be reinforced when the sea is sloshing toward the shoreline but when the blue sky hangs over a mild spring afternoon and the horrors of what might be sit in the mind like some horrible future vacation.

Early on in the pandemic I received a call from an old friend. Knowing that I work in the industry, he wryly asked, “This [COVID-19] must be great for business?” And you can’t fault his assumption, regardless of how callous it may now come across. Healthcare is a business like any other industry, albeit with the sacred responsibility of caring for human lives, and when the demand rises exponentially, as it has been portrayed over the past year, you wouldn’t be discounted for expecting to see a correlating rise in business. But that’s not how it transpired because while hospitals saw a surge in COVID-19 cases they saw a dramatic decrease in the number of patients visiting for treatments other than COVID-19, which represents a much larger percentage of the population.

But the whirlwind response to this new disease mirrors the complexities of the industry as a whole. Things are not what they seem. While we offer superior medical care in this country we seem to mismanage the kind of straightforward tasks more typically associated with warehouses and distribution centers. These pitfalls were remote until last March when reports emerged of PPE shortages, supply-chain obstacles. It would have been impossible to fathom that while hospitals reported their ICUs heading toward capacity the rest of the hospital was all crickets, seeing far less numbers of traditional high acuity visits. Not that there was less acuity in the population at large, only a depreciation in the number of people willing to visit hospitals, which were thought to be unsafe because of COVID-19.  People experiencing symptoms of stroke and cardiac arrest resisted going to the ER lest they contract the virus. Some died.  Cancer patients on immunosuppressant drugs stopped treatment programs or had crucial screenings pushed back. For months a stay was put on elective surgeries. The whole system took a backseat to COVID-19; conditions predating the pandemic in large part could not be managed alongside the bombardment of COVID-19 treatment. This is not how it should be.

The writer F. Scott Fitzgerald once defined the mark of a first-rate intelligence as someone who can balance two opposing ideas simultaneously while still maintaining the ability to think. We would have to declare the brain of this incredibly dexterous industry defective if put to this test. The defect is not in the care itself but in strategy and implementation, in logistics, how to get the kids on and off the school bus. I mean, just look at how transformative our industry has become in its treatment of a disease that wasn’t around a year ago. It’s unprecedented that we have a vaccine, that markedly fewer people are dying after they contract the virus because of innovations in the approach to caring for these afflicted people. The research and facility is staggering. But COVID-19 is only one of thousands of afflictions. There is no reason why hospitals should have to abandon these other treatments, as COVID-19 does not zap out all the other illnesses. They’re still very much there, just not in the news.

It is not surprising that hospitals and practices that had invested in digital and virtual care technologies long before the onset of the pandemic have faired best over the past year. The necessary diversification of care permits beleaguered doctors, nurses, and APP’s to see far more patients without being straightjacketed by in-patient care, which during a pandemic further imbalance a hemorrhaging system and increases the risk of contracting and transmitting the disease. Rural hospitals and practices that did not have access to these technologies faired worst of all.

In the coming months, as we begin to comprehend more and more of what went awry in the early days of the pandemic, we can’t lose touch with that sense of chaos and hopelessness in March and April of last year when we couldn’t locate the stockpile of ventilators and medical personnel were fabricating their own masks because of shortages in manufacturing and supply. Hopefully, if we can keep these images and feelings in our minds, it will spurn us on to working toward developing technologies that help more evenly distribute the anxiety across the system; to using newer technologies, cost effective transactions and a sharing of clinically relevant data to the benefit of the patients and those that serve them.

Interoperability: A Love Battle


It is in some ways flattering that in the great anonymous corners of the world there are known faction warring for our allegiance as consumers. We feel important, valued, both good feelings. This is perhaps one of the only upsides to a role otherwise troubled by a deluge of solicitations, misleading campaigns, trash beauty products, bad food, toothpaste, fad diets, false appeals to the heart.

Being vied for becomes a bit more muddled, however, in healthcare debates, an industry in which the consumer is even less surefooted due to the processes required in really getting a firm handle on that foreign organism that is the human body (I feel confident, for instance, making decisions about the right brand of cereal, yet I’d feel less good about applying that independence to heart medicine) and all the red tape that interferes with accessibility, not to mention the dire consequences of getting it wrong. But if you pay attention, bigwigs in the healthcare industry make appeals to us as consumers quite strongly too.

In February 2020, HHS announced that it’s adopting interoperability rules put out last year by the CMS and ONC aimed at addressing access, exchange and use of electronic information, and preventing healthcare organizations from using information blocking tactics. HHS director Alex Azar said the rules are “essential to building a healthcare system that pays for value rather than procedures, especially through empowering patients as consumers.” HHS, it appeared, made the decision with us at the fore of its mind.

Over the past few years much of the industry has begun shifting away from redundant fee-for-service models toward value-based ones. This has helped lower costs by pushing treatment courses on the merit of their effectiveness, not profitability. So when HHS announced it would be implementing measures for easier data sharing that push this evolution forward it was mostly seen as positive.

Yet shortly after the publication matters were complicated when healthcare software giant Epic, out of Madison, WI specializing in EMR and EHR software storage, sent a letter signed by an unavoidably lengthy list of hospitals citing concerns over patient privacy. Founded in 1970, Epic is one of the largest storage houses of EHRs so you would not be alone in seeing their defense as mere protection of a de facto stronghold using the guise of patient privacy to conceal this special interest. A more sympathetic view might see them as experts attuned to the complexities of software storage who worry that opening data sharing up for purchase and exploration by third-party IT groups might put at risk sensitive medical information.

The notable thing, though, is how both HHS and Epic cling to the noble position of being defenders of patient and consumer interest. But mark how differently, how interchangeably, the two employ the term consumer and patient, how malleable the term is, with HHS using the language of choice, empower, and Epic, defense and protection, and both reaching antithetical opinions over what is best for us. To be a consumer in this context is to be a very important abstraction, the most important empty chair in the room.

Regardless of who is closer to the truth both parties should take seriously their claims of devotion to the consumer by investing and not hamstringing innovations that might help solve some of the irrefutable headaches that plague this industry. As patients and doctors, as consumers endowed with the power of indifference and ire, it is high time for us to stop being seen as cynical pawns in this tumultuous debate over what is best for the consumer of healthcare while being largely excluded from the conversation. We should be courted as the formidable consumer base we are and looked at as discriminating entities more than willing to turn away from inferior practices, irrespective of which of our supposed protectors is claiming to hold us dearest.

Surprise Medical Billing (Balance Billing) Potential Federal Legislation


Update: Surprise Medical Billing (Balance Billing) Potential Federal Legislation

Many emergency medicine groups are currently out-of-network with major private insurers, and therefore bill patients the difference between their charges and what the insurance company paid (referred to as “balance billing”).

This scenario may cause friction with patients and hospital administrators, especially where the hospital itself is in-network with the payer. However, many emergency medicine groups believe the in-network rates offered by some private insurers are inadequate and leave them no choice but to remain non-par with those payers.

Such bills are often included under the term “surprise medical bills” because patients were treated at an in-network facility, but the provider group itself was out-of-network and balance billed the patient. Some states have already addressed surprise medical bills and pressure has mounted on Congress to take action at the federal level.

This month a flurry of activity on Capitol Hill has produced legislative drafts, hearings, and announcements focused on surprise medical billing. The Senate, House, and Administration have all announced plans to address the situation, including a number of possible approaches. All agree that the patient should be taken out of the process and be responsible for only their in-network deductibles and co-insurance.

Final legislation is likely to contain recommendations from legislative and other stakeholders, which propose various solutions, such as:

  • Set Rates: pay out-of-network providers a median in-network rate
  • Network Matching: require all hospital-based providers be contracted with the same payers as the hospital
  • Bundled Billing: prevent hospital-based providers from submitting claims or billing patients (the facility would provide a single claim, including professional fees; physicians would be reimbursed by the facility)
  • Consent: Require patient notification and consent to balance bill for out-of-network services
  • Arbitration: create arbitration processes for providers and payers disputing the amount of out-of-network reimbursement
  • Databases: create state-based databases to collect claims and payment data for all payers
  • Price Transparency: healthcare providers to furnish expected costs for services to patients in advance of treatment
  • Network Adequacy: requirements that insurers provide adequate networks

Innovative is closely monitoring the situation and will be part of a group visiting with congressional and administration officials in Washington next month regarding healthcare reform in general, and surprise medical billing in particular.

Innovative executives are actively involved in national organizations that help inform and guide policymakers on healthcare issues, including: Healthcare Business Management Association (HBMA), American College of Emergency Physicians (ACEP), Emergency Department Practice Management Association (EDPMA), American College of Osteopathic Emergency Physicians (ACOEP), Workgroup for Electronic Data Interchange (WEDI), and others.



One of the Internet’s gifts—and occasional annoyances!— is its space for people to self-publish their alleged expertise on a subject. Surely this must be some form of purging. I feel an odd mixture of depression and excitement toward these online message boards. The writers on healthcare forums vary from doctors, hospital executives, and private insurers, to young families whose finances have been wrecked by medical expenses.