Mastering the Basics: A Guide to Addressing US Healthcare Challenges

According to a Gallup study, seven out of ten people believe the present healthcare system is 'in a state of crisis' or has 'major problems,' which have persisted for over three decades. Despite spending more on health care than any other high-income country, the United States has a higher chronic disease burden.

Key Stakeholders in the Healthcare System

Before getting onto the key issues in US healthcare management, let’s first discuss the different stakeholders of the business.

The key shareholders of the management system are:

Patients: Individuals seeking healthcare services. They receive medical care, treatments, and services as the primary recipients.
Providers: Healthcare institutions and organizations that deliver services. They offer various healthcare services, employ professionals, and manage facilities.
Physicians: Healthcare professionals who are directly involved in patient care, diagnosis, and treatment.

Key Issues In The US Healthcare Management System

The healthcare industry in the US was about $4 trillion in 2021, roughly $12,000 per capita, and is expected to cross $6 trillion by 2028. Yet, healthcare has negative productivity gains, implying that extra investments diminish GDP returns.

Several reasons are driving this, such as:

Physician Burnout

Physician burnout is a critical issue affecting both the quality of patient care and the well-being of healthcare professionals. One major factor contributing to this is the inefficient use of time, often attributed to administrative tasks and electronic health record (EHR) systems.

For patients, prolonged waiting times rushed appointments, and limited face-to-face interaction with physicians can lead to dissatisfaction and a sense of being underserved. Similarly, for doctors, excessive paperwork and data entry are overwhelming. Since physicians now spend more time on admin responsibilities than direct patient care, they report high fatigue, stress, and reduced professional fulfilment.

Utilizing technologies like MarianaAI, which employs AI for automated transcription, can streamline patient interaction and reduce documentation complexity, leading to more efficient patient care.

Revenue Leaks

Administrative inefficiencies, such as redundant paperwork, billing errors, and delayed reimbursement processes, contribute to revenue leaks. The lack of streamlined communication and coordination between different healthcare providers and facilities results in fragmented care, hindering the accurate billing of services provided.

Studies reveal hospitals in the US waste $12 billion per year due to poor communication, which is often caused by ageing technologies, department silos, and other issues.

Furthermore, limited access to longitudinal patient histories often provides incomplete profiles causing suboptimal care. Resulting delays in diagnosis and treatment not only affect patient outcomes but also contribute to financial losses due to complications that could have been prevented.

Rising Healthcare Costs

It's no secret that healthcare in the United States is expensive, and the expenses keep on escalating. Spending hit ~$3.6 trillion in 2018, nearly $11,000 per capita. Centers for Medicare and Medicaid Services (CMS) projections estimate national expenditure will touch $6.2 trillion by 2028 due to:

Increase in drug prices: Pharmaceuticals have come under fire from the public after significant price increases for life-saving drugs. For instance, retail prices for more than 450 prescription drugs shot up 5.2% on average in 2020, more than double the inflation.

Technological Advancements: While enhancing diagnosis and treatment capabilities, cutting-edge medical devices and tools levy a huge price. R&D and implementation costs are key healthcare spending drivers.

Waste of resources: Resource Wastage: Inefficiencies in healthcare systems, such as unnecessary tests, procedures, or treatments, can result in the wastage of valuable resources, including time, manpower, and medical supplies. According to reports, the unwillingness and inefficiency of staff to prevent wastage contributed significantly to cost overruns – providers had to charge more for basic services while reducing their operating margins.

Healthcare Disparities

Per a Deloitte study, barriers to access may cost over $1 trillion by 2040. But more crucially, the real price is the avoidable loss of lives. Most Americans cannot afford quality care, or even access caregivers regularly.

Various reasons contribute to the disparity, including:

Stigma and bias: Prejudice based on ethnicity, immigration status, gender identity, sexual orientation, and other attributes is still common. Experts describe its crippling impact on marginalized groups’ willingness and ability to seek counseling, transition-related care, and other vital services. Even unintentional bias from clinicians and staff based on outdated medical information makes patients feel unwanted and hesitant to return.

Insufficient insurance coverage: Constrained finances and bare minimum health plans cause individuals to miss essential preventative screenings, dental visits, and child vaccinations with lifelong implications. Missing these appointments can have long-term negative effects on one's health, which is why many health systems have started programs to help patients who are underinsured or without insurance.

Language Barrier: Meeting patients' language needs is becoming a growing concern for healthcare systems, given that one in every five US households speaks a language other than English. When patients and clinicians do not communicate in the same language, it can have an impact on the quality of care that individuals receive, particularly in hospital settings. While many patients use family members as interpreters, this can lead to miscommunication and mistranslation.

Data Security Threats

Thanks to federal mandates, over 59% of the hospitals in the US and Canada now use Electronic Health Records (EHRs) for patient data storage, with more providers following suit. However, these systems are not without their own set of challenges.

The first consideration is the cost of simply purchasing this software. EHR software is not cheap, and it adds to the already-increasing cost of healthcare delivery. The use of AI-based tools over the past few years has enabled optimized healthcare operations for providers.
Training caregivers and office staff to use these new solutions takes time and investment.
Transitioning from legacy IT set-ups necessitates resources for system migration.

Moreover, data privacy remains a concern. Between 2009 and 2020, breaches exposed over 70% of patient records exceeding financial service and banking sectors.

In comparison to other industries, healthcare is relatively unprepared for cyber attacks. According to reports, hackers targeted more than 100 million patient records – surpassing the financial and banking sectors.

“Due to limited funding and budgetary constraints, many healthcare providers have become increasingly easy targets for attackers, who exploit their vulnerabilities.”

- Raymond Dacillo, Director of Operations at C-Care Health Services

MarianaAI’s CARE platform helps strengthen defenses by offering military-grade security offering remote deployment within organizational firewalls.

Solutions For Addressing Healthcare Management Issues

Undoubtedly, healthcare offers unparalleled diagnostics and cutting-edge lifesaving therapies today. However, as experts analogize, a single misstep can trigger cascading, potentially disastrous outcomes within this ecosystem of densely interlinked yet fragmented platforms, protocols, and stakeholders.

Ronda Hughes, professor and researcher, explained this using ‘Swiss cheese’ as an example. She says, “It (the Swiss cheese) actually represents what happens each and every day in health care. Each piece of cheese represents a person or a process – when they work well they're able to prevent an error from happening. But if those imperfections line up just right and error happens and then many times that can be life-threatening.”

Here are some solutions that providers can undertake to reduce their errors, standardize their system and make healthcare more accessible:

Integrated Delivery Models

Consolidated systems managing care delivery alongside insurance plans are better positioned to align incentives and adapt faster. A December 2020 study revealed integrated providers sustained lower pandemic impact.

Also, integrated systems can "balance the load" by moving patients across facilities, across space, and among caregivers, as well as, between care providers and insurers. They can also swiftly share knowledge and best practices.

The integrated approach allows the cost of delivering care and the cost of insuring care to be linked in ways that benefit both the insurer and the provider.

This is because when healthcare expenses are decreased, both parties benefit; when the healthcare system and insurance plan are separate, cost-cutting measures benefit the insurer or payers (e.g., employers), not the health system.

For example, Intermountain Healthcare owns a nonprofit health plan. Whereas SelectHealth collaborates extensively with partners like St. Luke’s Health System. Despite contrasting approaches, integrating quality care and coverage offers mutual benefits.

Value-Based Care

Value-based care enhances quality of life and corrects mismatched incentives (for example, compensating physicians based on the volume of operations performed rather than outcomes). It has the potential to lower healthcare costs by making care more accessible and keeping people healthy, which minimizes the number of treatments and procedures required.

For example, SelectHealth's focus on value-based care enabled it to cut its prices for people insured through the federal exchange by 2% to 3% during the last three years.

Value-based care also allows providers and insurers to create and execute a wide range of novel technologies that volume-based systems cannot. For example, Intermountain Healthcare is collaborating with the University of Utah Medical School to create a new medical educational program – the first of its kind in the United States – to train the next generation of physicians in population health, which focuses on keeping people and communities healthy.

Here are a few other strategies that helped Intermountain implement a value-based care model:

Aligning and restructuring provider panels: A provider's panel must include enough patients covered by value-based contracts (i.e., capitation) to make the modifications worthwhile and financially and clinically viable. Patients assigned to a provider must be a mix of those who are reasonably healthy and those who have chronic diseases that require more comprehensive and intensive care.

Restructuring teams and workflows: Once you have aligned the panels, you need to reform and adequately equip teams that support physicians to succeed in this new paradigm of care. Plus, you must update and implement the core workflows and processes, and arrange regular team meetings to coordinate patient outreach, fix care gaps, and organize care for the patient's changing requirements.

Educating providers and teams: Ensure that everyone is prepared to participate in this team effort by educating them on the key concepts of value-based care, regardless of how large or little a role they will play.

Using innovative technology: To harness and unlock the value of this data, use tools to connect disparate data sets and overlay complex algorithms. For example, with MarianaAI’s cutting-edge AI system, you can streamline the process of medical coding, reducing errors and enhancing accuracy. You can also use it to maintain complete and up-to-date documentation.

Financial incentives should be aligned: The incentives should be aimed at keeping people healthy rather than merely generating revenue.

Technology & AI Integration

Artificial intelligence (AI) is having a growing impact on healthcare delivery and administration. Along with machine learning, it has the potential to increase the efficiency of simple, repetitive tasks such as patient intake and scheduling. This allows workers to focus on more complex issues while saving time and money.

MarianaAI offers the capability to improve operational efficiency by automating labor-intensive tasks like medical coding and documentation. This reduces the likelihood of manual errors and liberates resources for other uses.

Here are some other ways that AI can benefit the healthcare management system:

It can help administrators staff more effectively by predicting staffing needs.
Doctors can use artificial intelligence to complete administrative tasks, freeing up time to focus on patient care.
Some administrators and health insurers are starting to use big data analytics and artificial intelligence (AI) to predict health risks and track and analyze disease outbreaks.

Moreover, telehealth—use of electronic information and telecommunication for long-distance clinical health care—brings experts such as neonatologists, neurologists, and cardiologists to rural hospitals. All this without having the patients moved to larger, more distant facilities.

They can stay in their neighborhood, surrounded by their support systems, with the majority of the compensation going to the local hospital. This benefits not only remote hospitals but also rural towns in which hospitals are sometimes the main employment.

However, these are just tools; they aren't magic. To make the most of them, we need cross-functional teams of medical professionals, scientists, nurses, researchers, and tech experts working together.

Also, providers must address security challenges, particularly those caused by organizational issues such as inadequate personnel training. There have been various instances of leaked health records, the majority were compromised as a result of unintended disclosures by staff.

The Bottom Line

Think about it – even a small misstep in managing healthcare data can have long-lasting and tragic consequences. These errors may not become apparent for years, and by then, it may be too late.

This isn't just about one individual or one condition; it's a colossal effort. The healthcare management system relies on the collaboration of talented individuals, advanced technology, and the empathy that comes from a deep sense of caring.

Every piece of data, every diagnosis, every prescription, and every interaction is a crucial thread that needs to be stored and managed well. Because in healthcare, there is no room for errors or complacency.