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Redesign The Health System--Or How I Spent A Really Bad Summer Vacation.

Posted by: Bruce Nussbaum on August 31, 2007

Sorry for the long silence but I’ve been dealing with a serious family medical problem. It highlights the desperate need for design and innovation in the medical space. If you think flying is a horrible experience, try getting sick.

Here’s what happened—a family member started having symptoms of a possibly deadly illness. The kind that can kill you suddenly and quickly. We went to a specialist who said get tested ASAP. He said that at 8AM that morning. The testing facility was next door so we were ready by 9AM. But the Oxford HMO wasn’t. We needed to get pre-certified to pay for the test. OK, how hard can that be if the doctor said the test was needed ASAP?

There was a full-time person at the medical testing facility working with HMOs and she looked at me with sad eyes when I said “this will take a few minutes, right?” No, “it usually takes between three and five days,” she said as she began faxing material to Oxford.

Actually, the faxes went to something called Care Core National, which is the gatekeeper for Oxford and other HMOs. It has doctors who say “yes” or “no” on whether or not your HMO will pay.

One fax was sent and a confirmation received. A call was made to Care Core, which said nothing came through. A second fax was sent and a confirmation received. Another call was made to Care Core—again it said nothing was coming through. A third fax was sent and confirmation made. Care Core then said that sometimes it took two hours for a fax to get through. What about the confirmations? They didn’t know abou that. As for the “ASAP,” sorry.

I called Oxford directly and a polite woman told me that that the “case” had gone to review. That means that it was before the Care Core doctor who was deciding whether or not Oxford would pay for the tests that our specialist had said were necessary ASAP. So the faxes had gone through. Hmmm.

At this point, over two hours had passed and since the tests took hours to complete, we were in danger of missing the entire day. I said we would pay for the tests privately. Just get it done and we would deal with Oxford later. The people at the testing facility gave me another mournful look—Oxford never pays if you do that, they said. And if you need an operation, you won’t have precertification. You might have to pay for all of it.

What a nightmare. The clock is ticking, the faxes are either going through or not and some doctor somewhere is deciding on what a specialist in the field has already determined to be an emergency.

As we’re getting up to take the tests and pay privately, the testing facility calls one last time and Care Core approves. It took three hours to get the OK. At this point, of course, I don’t really give a damn.

If anyone from Oxford or Care Core is looking at this blog, here are a few simple tips to redesign your process so you don’t kill anyone anytime soon:

1) Simply have the specialist doctor telling their patient to get tested email directly your gatekeeping doctor with the request and information. Cut out the army of adminstrators in-between.

2) Drop the faxing—everyone else in the world has—and do it digitally. It makes it all so much faster and cheaper. Unless you really want to slow everything down and delay the process so people go away, pay for themselves and your profits go up.

3) In emergencies, let people pay for their tests and compensate them after if it’s warranted. It’s faster and cheaper. End the pity in the eyes of testing people when patients say they’ll just pay themselves and get it back later.

4) Bring in some great design consultants who can redesign your process and business model so you can actually boost your profits while increasing the service you provide to your customers.

Redesigning the medical system has got to be one of the most important issues of the upcoming Presidential campaign in 08. Anyone who has someone who touches that medical system just once knows what I mean.

Reader Comments

Stephen Macklin

September 1, 2007 1:18 PM

Unfortunately for most people "redesigning the medical system" means let the federal government take it over. When that happens you will look back on the three hours it took to get an emergency test approved as the good old days.

The problem with the Insurance system as it currently exists (thanks to the way the government set up THAT system) is that health care decisions are in the hands of people who really don't care if you live or die.

Anyone who expects full on socialized medicine to be an improvement on that is whistling past the graveyard.

Chris conley

September 3, 2007 1:58 AM

My best to you and your family as they diagnose/work through the actual illness. The experience you describe is exactly why innovation firms use ethnographic research to assess the customer experience despite what some policy manual might say. I bet a lot of executives at Care core are confident that they "know their business" and "drive for results." Unfortunately, they don't realize they can have their cake and eat it too. Imagine the word of mouth benefits that woud go to the HMO that expedites approval and cares for their customers all at a fair market return. Where is the passion and imagination for creating a great business?


September 3, 2007 9:25 AM

In stead of redesigning this process, you could also cut out these companies altogether and redesign the entire system. Because the bottom line is these companies don't really need to compete on customer experience. Not "buying" their "product" isn't really an option when you're sick, is it? Healthcare should be about people, not profit.

Get yourself some free and universal healthcare over there and stop being so scared of "socialised medicine" ;-).

Chris Gielow

September 5, 2007 7:13 PM

For all the inroads design has made in the last decade, it is still largely absent in the field of healthcare. I recently attended a patient safety conference and found it indistinguishable from a design conference, less designers in attendance. Ignorance? Disinterest? Let's continue to raise the discourse and deploy design thinking to this critical area.

Don Raleigh

September 8, 2007 2:08 AM

I am a nurse and I can only add that I feel your pain also! I am currently working on a master's in nursing informatics and looking into information systems and design in order to improve health care for everyone involved. Best wishes to you and your family member.


December 28, 2010 8:49 PM

This is great that people can take the loan and this opens up completely new possibilities.

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Want to stop talking about innovation and learn how to make it work for you? Bruce Nussbaum takes you deep into the latest thinking about innovation and design with daily scoops, provocative perspectives and case studies. Nussbaum is at the center of a global conversation on the growing discipline of innovation and the deepening field of design thinking. Read him to discover what social networking works—and what doesn’t. Discover where service innovation is going and how experience design is shaping up. Learn which schools are graduating the most creative talent and which consulting firms are the hottest. And get his take on what the smartest companies are doing in the U.S., Asia and Europe, far ahead of the pack.

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