Opening my mail today, there are multiple letters from multiple insurance companies, reportedly communicating valuable information to me about my panel of patients that they cover.
One of the envelopes holds two single sheets of paper, one of which contains a listing of my panel of patients and the providers they have been referred to over the past quarter.
The second sheet, mysteriously, contains only a single line: This page intentionally left blank. I flip it over to look to see what was on the other side, something really useful, a secret code that I could use to redeem valuable cash prizes.
Although I didn’t have a lot of time to spend thinking about it, I found myself thinking about it. Why did the insurance company insert a second sheet of paper, noting right on it that it was intentionally blank (even though just typing that it was blank made it not actually blank)?
This brought to mind the endless waste and inefficiencies built into our health care system.
What rule somewhere back along the line made them add a second sheet of paper to this letter they were sending me? Was there a minimum weight requirement for their mail? To be able to receive a special shipping rate were they required to have at least two sheets of paper, not one, in every letter they sent?
Or was there some budget allocation that required the insurance company to expend their stationery budget for the year, or else next year they would not be able to ask for as much money from their parent corporation?
Recently a sixth grader doing a science project estimated upwards of $100 million in savings for the federal government by simply changing to a thinner font on all the documents they printed. Thinner font, less toner, less paper. Simple and elegant.
We need to take this lesson in hand when attacking the dramatic waste that seems to be so firmly entrenched in our current health care system.
Let’s start with those letters from the insurance company. As I have written before, every day I get dozens and dozens of administrative, bureaucratic, regulatory pieces of mail, usually with little added value to the care of my patients and more and more work needed for me. A list of patients enrolled in a certain plan. Patients seen at an outside emergency room that the plan was requesting prompt follow-up. Various database-driven measures of my performance, along with not-so-subtle requests that I do better.
These letters in and of themselves are not only wasteful, but they’re emblematic of the waste in the system. I don’t need to know that my patient was seen last week or last month in some emergency room. I need a system to keep them out of the emergency room. Why has this same insurance company allowed us to build a system such that patients do not have access to the care they need when they need it, where they need it, so they do not need to rely on the emergency room? Why are they requiring me to fill out a referral for a specialist, when specialty care may indeed be clearly warranted; or, if the patient had been able to see me, then maybe that more expensive visit with the subspecialist could have been averted?
I’d like to save the cost of toner and paper and postage for the insurance companies, but even more critical is fixing a system whose waste leads to this waste.
We know that lack of continuity of care and doctor shopping lead to excessive testing. Whenever a patient of mine is seen in another setting, and someone who doesn’t know them tries to figure out what is going on and what I’ve been thinking, everyone over-orders tests, we do a lot of CYA, we do anything we can because ordering tests, labs, scans, is easier than the hard work of finding out what’s really going on.
All of the components of a patient-centered medical home have the potential to add value to the care of our patients, while fostering systemwide changes that should decrease waste. Access to care when patients need it, and continuity with a team that knows them. Development of quality systems to promote better care. Returning the patient to the center of the care team, rather than the insurance company or even the providers. Safe transitions from inpatient to outpatient, office to office, back to community care.
The health care landscape has become so cluttered and noisy that we cannot see our patients standing in the middle calling out for help. We need to make a clean start, a fresh sheet of paper on which to write our new model of care.
The page is blank; it is up to us to fill it in with something that works.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.