Patients Are Avoiding Care. Are Policies or a Complex Health System to Blame?

The everyday struggle to find and pay for healthcare has become a worrisome burden for millions of people. Every step of the process feels more taxing than the next. Administrative needs coupled with insurance authorization requirements have created huge challenges. And the opaque billing process, with provider cost controls looming in the background, often creates delays in care or, in some cases, discourages care altogether.

Patients avoid seeking care

According to a recent survey of nearly 2,000 consumers nationwide, 6 in 10  consumers say the healthcare experience is so bad that they would avoid seeking care. And nearly half admit to avoiding care due to difficulties navigating the healthcare system.

It’s vital for the healthcare industry to acknowledge the vexing complexity of our healthcare system and work toward solutions that streamline rather than complicate—especially as the COVID-19 pandemic brought these issues into sharper focus.

Consumers want a simple patient experience. They want greater coordination between insurers and healthcare providers, and they prefer to have all medical information from providers in a single application. Although these improvements may seem simple to solve, this will require the right tecnology, colloboration, and policy changes to enhance patient satisfaction and meet consumer demands.

Lawmakers look to intervene

We all feel the sense of urgency to confront this mounting challenge. Lawmakers introduced legislation to streamline the revenue  process, mandating that insurers must establish an electronic authorization program. This is crucial, as the prior authorization process is critical in the front of revenue cycle with patient access and mid cycle with revenue integrity. While this bill limits the scope to Medicare Advantage, there is widespread, bipartisan, multistakeholder support for standardizing electronic prior authorization transactions across the industry to reduce friction, time to delivery care/treatments, and administrative costs.

Some of the new legislation is informed by an HHS report released earlier this year, which detailed “prior authorization” use within the Medicare Advantage program. The report summarized finding that the organizations managing care for more than 20 million recipients denied 13% of prior authorization requests for care that met coverage rules and denied payment requests for 18% of claims that met billing and coverage rules.

Fragmented systems create friction

On average, it takes healthcare organizations a little more than a day to get a patient scheduled, registered and financially cleared for an appointment. And clearing patients is a group effort, requiring about 20 different people within an organization. With each step, pain points arise for consumers as they confront fragmented systems, eligibility requirements and records regulations.

Even communicating with the patient is a challenge due to gaps in coordination and messaging between clinical, financial, and operational functions. Journeying down the patient pipeline of registration, patient billing and collections, and claims management with half a dozen more steps in between, the provider often uses separate systems and multiple technologies to manage the operation. Providers can have an overwhelming number of vendors involved in the patient experience--one provider reported over 160 vendors. This leads to disconnected systems, budgetary burden, and miscommunication among stakeholders, leading to a poor patient experience. This doesn’t have to be so challenging.

Patients want personalized experience

Even before the pandemic, the healthcare industry faced large-scale change as digital communication became the preferred medium for scheduling services and communicating with providers. As expectations rise with the further digitization of daily life—from paying bills online to ordering a ride-share service—consumers want similar conveniences in their healthcare experience. And with patients now on the hook for more of their medical costs, they are becoming savvy shoppers, looking for healthcare to replicate the consumer-centric experience that now occurs in most other industries.

A consensus is building on what a better system looks like. For most providers, a personalized experience across the entire healthcare journey is the goal. Any patient-provider interaction should be positive and patient-centric. Just as clinical care is focused acutely on the needs of the individual patient, the patient’s financial journey experience should resemble the same level of attention and care.

Promising solutions ahead

But there’s more that needs to be done. Healthcare is a highly regulated, complex industry. Innovation on the scale that’s needed will require real collaboration across specialties, practices, and providers.

We’ve seen a major shift toward a digital-first patient experience in the healthcare industry over the last few years. Nontraditional players in healthcare—such as Amazon, CVS, and Walmart—hold promise as they attempt to provide a patient-centric experience using their technology and scale. Also promising, technology keeps developing to provide consumers with a digital-first patient care journey. Expansion in telehealth, new mobile health applications, streamlining patient communications, and video screenings will all help facilitate growth in digital patient care.  

As an industry, we cannot have patients turn away from care because they’re overwhelmed or discouraged by systems designed to serve them. Ultimately, healthcare organizations and the technology solutions they adopt need to be mindful that there is a patient on the other side of their processes. Improving the patient experience and creating a fully connected, seamless encounter is a worthy ambition that we must strive for.