Michael Anne Kyle and Austin Frakt released a pretty awesome paper last week in Health Services Research. They ask — for five basic types of administrative functions related to medical care, do people not get the care that they think they need because of burden of completing a task?
YES!
We assess the prevalence of five common patient administrative tasks—scheduling, obtaining information, prior authorizations, resolving billing issues, and resolving premium problems—and associated administrative burden, defined as delayed and/or foregone care….
Seventy-three percent of respondents reported performing at least one administrative task in the past year. About one in three task-doers, or 24.4% of respondents overall, reported delayed or foregone care due to an administrative task: Adjusted for demographics, disability status had the strongest association with administrative tasks (adjusted odds ratio [OR] 2.91, p < 0.001) and burden (adjusted OR 1.66, p < 0.001). Being a woman was associated with doing administrative tasks (adjusted OR 2.19, p < 0.001). Being a college graduate was associated with performing an administrative task (adjusted OR 2.79, p < 0.001), while higher income was associated with fewer subsequent burdens (adjusted OR 0.55, p < 0.01).
This is a unique study in that it looks at the process of arranging care and working with payment systems to get care paid for instead of the more common administrative burden literature that looks at program enrollment. These individuals are already enrolled into some payment mechanism (employer insurance or Medicare or Medicaid etc) but they still face significant burdens in using their payment mechanisms to get their needed care. I know that I will be citing this paper a lot over the next few years to justify my ever deeper and more esoteric dives into the ACA and Medicaid.
There are a few common threads. Burden is not random nor uniform. Instead, it is concentrated heavily on people who have enough other challenges going on in their lives. College graduates and people with money are able to use their pre-exisiting skills and inclinations to navigate complex bureaucrat entities with relative easy. They are also likely (I am speculating) able to choose providers and/or payment systems that are lower burden in general. Burden is a little invisible tax on time and cognitive capacity for healthy upper middle class folks but a significant drain on resources and attention for individuals who routinely interact with the medical system and who can’t just throw money at a problem.
Four Seasons Total Landscaping mistermix
Now do burden on providers and provider practices- having to contact an insurance company for approval of every little thing, the hundreds of appeal letters, the massively overcomplicated forms, and the extra staff hired simply to do insurance. One of the big wins of a single governmental healthcare system would be that the providers and staff would just have to learn one set of rules instead of hundreds.
Betsy
We love suffering in this country. We promote and accept administrative burdens and red tape. We regard those who find this intolerable as spoiled or not accepting of hardship. We like to be able to assign a little personal blame to people if they have poor health due to lack of treatment.
it’s the same basis that we tolerate constant junk phone calls the burden of processing junk mail, listening to loud cars and leaf blowers, or the bang of dumpsters at 5 in the morning. Crappy public services, transit that breaks down, neighborhoods without sidewalks, shitty benches at bus stops. The burden of dealing with 1000 small or medium sized daily hardships and nuisances and noxious crap, that add up to a total poor quality of life when taken all together. We just love hardship. We think suffering is important to life.
And we blame people when they complain about crap like this; we say that they’re spoiled or yuppified or entitled or whatever.
We love being able to assign blame to people. The suffering is the point.
MattF
I’d add record-keeping to administrative burdens. I’ve put all my health-care eggs in one basket (Medstar in the DC/MD area) because of that– and even that one organization divides its record-keeping into multiple incompatible pieces.
Ohio Mom
Even those of us who are college-educated and savvy about navigating systems sometimes throw our hands up in the air. Admittedly, I’ve always managed to collect myself and start again, so far.
I do worry about Ohio Son after we’re gone. Someone whose disability includes not consistently interpreting their body’s signals needs caretakers who are both attentive and assertive about getting vague symptoms addressed.
That’s pretty common in autism. A friend’s teenage son said he thought his ear might hurt. When they got to the doctor, he was amazed at the ravaging infection he saw which had caused a hole in the ear drum.
Everyone knows the five senses but there are also the sense of where our body parts are in space and in relation to each other (Proprioception), and the sense of what is going on inside our bodies, e.g., hunger, pain, fatigue, etc. (interoception).
Sorry to go off topic.
Betsy
I’ll say this too, the administrative burden of changing health insurance with all the red tape and crap, prevents people from changing jobs, or going to better jobs.
Right now I’m looking at a $60,000 a year job offer, but I know it will mean going off of my free Obamacare, and having to find a whole new bunch of providers, and having excessive co-pays and other crapola.
I can get all that for free and almost zero paperwork and keep my existing providers if I just keep my income below $18,000 a year. I’m seriously thinking about turning down the job and just toughing it out on the lower income, and having my free time to myself and not having to go through a blasphemous commute every day.
I know not a few educated skilled people like me who are avoiding higher paid work, or more extensive work hours, because it would kick them off the ACA subsidy cliff.
This is no way to run an economy.
MattF
@Ohio Mom: Coenesthesia is another good word in that circle of concepts.
bbleh
ARGH! This has been a pet peeve of mine for a while. (IMO this is one of those “water definitively found to be wet” studies.) And it has been GETTING WORSE. Both providers and payers are forcing more of the administrative burden onto the patient. For example, getting “insurance referrals” (which, I learned, are DIFFERENT from what used to be called simply “referrals” but now are considered “medical” referrals) is in many cases left to the patient rather than being handled by providers’ offices or just following automatically from medical referrals. And getting records from one place to another is now hit-or-miss; a patient needs to check whether records from a specialist will be sent to a PCP or whether additional forms must be filled out (which usually have to be done at the PCP’s office, not the provider where the service was received).
And we wonder why we spend almost half again as much per capita on healthcare related cost as the next most expensive nation. [Narrator: no we don’t.]
gvg
I only have the once a year having to check to see if I still selected the plan that offers me the best care. My employer (large state university) offers 6 or 7 plans each year. I never have any problems with billing or what not. This college town, a large majority of the population are on the same insurance so most places take it. They know how to bill for it. 1 hospital didn’t come to an agreement this year so if I need it, I will go to the other one, which is the Universities own teaching hospital.
7 years ago I had cancer. 1 small bill didn’t get covered at first but the hospital persisted and it did later. I never had to worry, and while undergoing surgery and chemo, I didn’t need any stress or complicated thoughts.
Everyone should have this. There is no valid reason to try to torture people with our healthcare system. It is possible.
I think the fact that my employer is such a big part of the economy around here gives them a big advantage. Everyone knows how to bill their insurance. Insurance doesn’t dare offend them. They have dropped companies before and chosen new ones.
All dental insurance sucks however.
Monala
I recently became disabled and had to stop working. I was just approved for long term disability benefits through my employer. I have already experienced the administrative burden of dealing with medical bills and appointments.
My coworkers did a fundraiser for me to pay for COBRA for about four months. After that, I will need to apply for Medicaid. (I also have a teenage daughter to cover). I’m concerned that the administrative burden and fights to get the care I need will increase once I’m on Medicaid. Any sense of whether or not this is the case, and what I can do about it?
WV Blondie
There’s an aspect to that “administrative burden” that the study doesn’t mention – how much money the insurers make if the customer throws up her hands in confusion and disgust and sticks with the status quo.
I turned 65 last October. I called my then-healthcare provider in early September to find out how to end their coverage and switch to Medicare as of Oct. 1. The customer service rep told me to contact them on Sept. 30 and cancel the insurance – but to wait until that day so I didn’t have to go without insurance at all. I dutifully called them that day and cancelled.
In January I went to my primary for my annual check-up. After, the clerk told me that Medicare had refused their submission because I was “three months behind on my premiums.” I called the insurance company – they apologized, said they’d take care of it – and two days later my doctor’s office called to say it was still frozen.
It took getting Manchin’s office involved to get it fixed (including sending me a revised ACA subsidy tax doc). AND did the insurance company ever reimburse the federal government for the three months of subsidies they took? I have no idea.
Cheryl from Maryland
Another issue is that practices in large areas use call centers — My husband had a bladder infection but cannot pee on demand. The call center said to bring in the sample the next day. The practice refused to accept it as they “weren’t the call center.” The technician was not pleased when I demanded an apology from her office for not accepting the call center’s instructions and that she needed to take responsibility for what the call center said and accept the sample. She threatened to call security. Four days to try to get an order to the technician. Did get an apology from the doctor, but by then it was a holiday weekend so it was a week to get treatment. Seriously considering changing doctors.
Betty
@Cheryl from Maryland: That was going to be my complaint. It has become ridiculous. The paperwork for providers requires a big change to the system which I doubt I will see in my lifetime.
bbleh
@Cheryl from Maryland: yeah, and the call centers answer the phone as though they are the specific practice, presumably because the computer tells them what number is being called into, so it’s very deliberately confusing. It’s only later that some back-office PA or RN calls back from the actual practice and then (in my experience typically rather rudely) informs you that that-wasn’t-us.
WereBear
This is one of my own Circles of Hell.
Systems designed to frustrate, personnel trained to be vague, constantly conflicting information, and website where the navigation takes a person to new and puzzling pages with hidden parts.
I have found that much of the time, routine things become routine, but the slightest deviation — their’s or mine — will throw it all off a cliff again.
Fraud Guy
In addition to the intentional hurdles, this is another example of outsourcing of service to the end user.
taumaturgo
But it is the way the economy is run, the question becomes, who reaps the benefits?
NutmegAgain
And how! I just discovered a new gap in knowledge–mine and the providers’–that has a big impact on the cost of care. I have an individual level policy, Gold, but tiered (in my state the choices are very few–wish I could still afford to live in MA, but that’s a different discussion.) When my provider calls for a procedure/test/whatever in my case, MRI, because I have a tiered policy, different imaging facilities are ranked differently within the insurer’s scheme. Yet, no one know about this, until after the billing. Yep!
So, I just got billed an additional $775 for a MRI that I had done at a “within plan” site. Yes–within plan, but–a ha!! tier 2, not tier 1. I called the insurer (Anthem BC/BS) to ask what imaging centers ARE tier 1, since I need my neck done, in addition to my lumbar spine.
Anthem told me there were no tier 1 imaging centers in the state of Connecticut. Hmm. Doubtful. I mean, really?
The upshot is that in addition to living with constant gnawing pain from a deteriorated spine and all that’s associated, my insurance is giving me the gigantic round-a-bout. so fun. (And, salt in the wound, my kid lives in Germany and has incredible health care, with unimpeded practically instantaneous access. grumble)
bbleh
@Monala: in my experience, it depends heavily on the state — since states administer Medicaid, and requirements and procedures vary by state — and even on the locality, eg if you’re in an urban area, because of how busy / professional the office staff are.
One thing to be sure to check is whether your current provider accepts Medicaid and whether any medications you need are covered. That in turn will depend on which plan / insurance companies you choose (assuming there is a choice), since most (all?) states contract Medicaid to major inscos. Some homework up front is strongly indicated imo.
SpongeBobtheBuilder
I am an over-educated financially-resourced person, and I am currently trying to figure out what optical care is covered and where to get optical care via my HMO. The spouse and I are both from low-income families and have been trained by years of being told not to waste money on doctors. Then once we got our own access to doctors, we were stuck in unpredictable PPOs and never knew how much to save or budget for anything because who can tell? They never list their prices for anything. We are finally in an HMO which we have loved, but even that has had financial unpredictability. Our teen needed to have their wisdom teeth removed. We called our dental insurance and found out that they would only cover a little of it. So we got the price and set aside $300/month in an HSA so we would be able to pay for it. Finally scheduled the surgery this July and discovered that the HMO pays for all of it. And here we thought the HMO pays for everything BUT teeth. So we have an HSA account with $3600 in it we need to spend. We all wear glasses, so we’ll each get the best glasses we can find, and perhaps prescription sunglasses, too. But anyway, I can see where this would be so much more burdensome if you had no money and little authority in your life.
Ted Doolittle
@NutmegAgain:
Nutmeg Again, if you live in CT (or you work for a CT company), the State Office of the Healthcare Advocate may be able to give you advice, or even free representation.
see our website at http://www.ct.go/oha
or email us at healthcare.advocate at ct.gov