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

7:00pm EDT November 25, 2010

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.

How can navigation be eased?

There are some alternatives being discussed, such as group appointments, which could expand the time a patient is with a doctor and possibly improve the discussion of conditions and treatments.

Group appointments not only save time but also provide patients with peer-to-peer interaction that the patients can relate to. When you have a group of people who share the same condition, they can talk about their experiences in a way that only someone with firsthand experience can, and they can be very effective in transmitting some information about their conditions.

Can an integrated delivery system make a difference?

Integrated delivery systems are another possible way that navigation of the system can be eased. Integrated delivery systems — which are networks of health care providers and organizations designed to provide coordinated services to a defined population — allow multiple health services to be managed by the same organizing entity. This can improve coordination of care and be easier on the patient.

A health plan can be an important part of this because it has access to all of the claims data of its members and it has the capacity to share that information with providers. That way, a provider gets a clearer picture of a patient’s condition and history and can make more effective and efficient care decisions.

What are some consequences of poor navigation?

Poor navigation compromises both health care efficiency and clinical consequences. Health care consumers pay the price for poor coordination of services. There can also be inappropriate utilization of services.

For example, when an emergency room is used for non-emergencies, the ability of ER personnel to do the best they can is compromised. Any time care is provided that could have been delivered in a more appropriate setting, costs are increased and quality of care can sometimes be diminished.

How can businesses help the situation?

Businesses have the capacity to work with a health plan to set the agenda for their employees who purchase health insurance. Initiating healthy lifestyle changes, rather than just reacting to illnesses, can prevent healthy people from developing chronic illnesses, and can also improve quality of life for those who already have chronic illnesses. Promoting a healthy environment in the workplace requires time and commitment, but will benefit both the employee and the employer in the long run.

S. Ramalingam, MD, MBA, is the senior medical director of medical management for UPMC Health Plan. Reach him at (412) 454-5702.