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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.
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