How businesses can benefit from helping employees understand today’s complicated health care system

People often talk about how complex the American health care system is, but that is somewhat misleading. There is no one American “system” of health care; that fact probably accounts for much of the complexity.

Confusion can even begin with something simple, such as the place where a consumer of health care receives that care. Should it be in a doctor’s office, at an emergency room, at a clinic, or at a hospital?

“In order for patients to get quality care that is timely, appropriate and affordable, they must be able to navigate the health care system in an effective way,” says S. Ramalingam, MD, MBA, the senior director of medical management for UPMC Health Plan. “Part of the reason things are so complicated is the fault of the system, and the barriers that are part of it. The way to approach health care is through the triple aim objective: improve the quality of care, improve the experience for the patient and improve efficiency.”

Reaching those goals can be challenging due to the complexity of the health care system.

Smart Business spoke with Dr. Ramalingam about how best to navigate the system.

Why is complexity of the health care delivery system an issue of importance to consumers and employers alike?

A complex system that is difficult for consumers to navigate compromises both health care efficiency and clinical consequences. Both results are unacceptable, one in terms of costs, the other in terms of the health and well-being of employees.

When the system is too difficult to navigate, patients may respond by delaying care, may fail to get any care, or may get it in an inappropriate setting, such as an emergency room. Such results not only drive up the cost of care, but reduce its effectiveness.

Complexity adds to misunderstanding and miscommunication. Miscommunication can result in overuse, underuse, or inappropriate use of services and rises in costs. We need health care to be both simplified and coordinated. The effort must be made to fix the disjointedness of health care.

Why is navigation of health care so difficult?

Navigation of health care requires coordination of care, which is a role that has traditionally been handled by generalists —that is, primary care physicians.

However, today many people get much of their care from specialists. As a result, the patient often receives what could be called fragmented care. There’s no coordinating with a central party.

That is why patients need one place they call their ‘medical home.’ It can be a PCP or a specialist, but it needs to be one place where all their information is kept and coordinated.

Health plans understand one of their most important roles is to coordinate and facilitate a patient’s information with the people who deliver the care.