Since I'm years away from collecting on Medicare, I tuned out during the recent discussions about the system. Then, last spring, my father took a bad fall that landed him in the hospital. Despite having Medicare and a good secondary insurance policy, his survival depended on my ability to quickly learn how to navigate Medicare's convoluted structure and decipher its hidden codes. As a designer who creates user-friendly brand and communication programs, I found it necessary to envision solutions to the seemingly endless problems that plague this confusion-riddled, fraud-laden, money-squandering monolith.
The paper chase
As my father was air-lifted to the hospital, my 80-year-old mother, overwhelmed by the swiftness of events, had to immediately produce a Health Directive, Living Will, Power of Attorney, Medicare Number, Secondary Health Insurance Policy and Prescription Drug Card. These are discrete documents, which all come in different formats and are produced and distributed at different times. Even if you have them, finding the latest version can be a challenge. Imagine if you had to provide a bank balance, credit history, utility bill and birth certificate every time you made a credit card purchase! The wasteful and labor-intensive process of generating and collating the same information repeatedly became a recurring theme throughout the year ahead.
The problem begins with language
Although Medicare and Medicaid sound quite similar, they couldn't be more different. "Medicare" is health care insurance (similar to what most of us under 65 pay for privately) while "Medicaid" is healthcare for the poor -- in many cases long term nursing care. Then there is "Medicare Part A" (hospitalization and nursing facilities), and "Medicare Part B" (doctors services and tests). Most of the terminology obscures rather than conveys meaning. Not only is it difficult to understand, but the rules and criteria for benefits are constantly changing.
"Acute" or "Sub-acute" are designations for the kind of facility one may be eligible for based on your medical condition. In translation, "acute" means "hospital" and "sub-acute" means "nursing home." (No one actually explains this.)
Social Workers are assigned to each patient. According to the US Department of Labor website, social workers "provide persons, families, or vulnerable populations with the psychosocial support needed to cope with chronic, acute, or terminal illnesses?" After several interactions I realized that "social workers" are actually government watchdogs -- making sure you don't overstay your allotted days in any given facility.
Unfriendly user information
Medicare is a bit like cottage cheese -- it has built-in expiration dates. Except with Medicare, none of the expiration dates were clearly visible and the criteria for reaching one never clearly explained.
After thirty days at the hospital, the "social worker" provided us with a barely legible list of "sub-acute" rehabilitation facilities, and informed us that my father had to be discharged the very next day. To learn more, I went to Medicare.gov, where the primary elaboration was a list of violations for each facility (for example, "percent of high-risk residents who have pressure sores (13 percent national average!)", percent of residents who are more depressed or anxious (15 percent national average"). I got depressed just reading the criteria! In lieu of usable information, I resorted to old-fashioned networking to determine where my father went next.
The scariest failure I encountered with Medicare was the absence of systems to ensure continuity in the exchange of information, which meant there was no continuity in my father's care. Reams of paper describing his cerebral hemorrhage (bleeding of the brain), bradycardia (irregular heartbeat), pharyngeal dysphasia (difficulty swallowing), hypothermia (low body temp), and anemia (low white blood count) were faxed to his new facility, but unfortunately, his doctors didn't make the trip. As a result, twelve days later he was back in the hospital suffering from a recurring infection that -- without the proper translation -- looked like a stroke.
Astonishingly, the hospital had no record of him and assigned all new doctors, none of who seemed to be aware of the 20 medications he was taking. All I could think about was how Amazon welcomes me by name and suggests new books I might like. How is it that the healthcare system has no central database for the various medical professionals who encounter a patient? After all, my summer reading list is not a matter of life and death -- but the medical treatment I receive often is.
My mother began to get pounds of paper from Medicare. And pounds more from the secondary insurance company, not to mention individual bills from cardiologists, anesthesiologists, oncologists, radiologists, psychologists, urologists, helicopters, ambulances and hospitals. They contained page after page of doctors exams and procedures: electrocardiograms, echo exams, Doppler echo exams, Doppler color flow ad-ons, chest/neck/spine X-rays, chest/abdomen/pelvis CT scans, ECGs, airway inserts and mileage! A quick scan of the individual costs was frightening. $980, $692, $575, $331, $133. $468, $107, $214, $107, $214, $107, $214, $307, $214, $107, $321, $107, $107, $107, $468, $75, $110, $75, $600.87, $296, $91, $91, $91, $91, $91, $75, $75, $75, $75, $91, $75, $75, $75, $456, $400, $200, $148, $2134, $653, $653, $425, $360 These were all on the first statement!
Medicare, the insurance companies, and the doctors all have different computer programs and formats, making cross-referencing bills and payment nearly impossible. The secondary insurance company pays its portion once Medicare has paid. Despite Medicare's approval we began to get "scare letters" from the secondary insurer saying they'd deny the claim unless they received certain information. How could this be? It turns out that the insurance company's computer system accommodates fewer characters per line, so half the information drops off when Medicare passes on the claim. The doctor then had to resubmit the same information all over again.
Perhaps most shocking revelation was that Medicare pays a fraction of the costs. A $692.00 bill for 5 x-rays? Medicare paid the provider $112.51. A $60.00 electrocardiogram report? Medicare paid the provider $7.76. How can the hospitals and doctors survive when their fees and expenses are so highly discounted?
Federal guidelines allow for a 30-day "hold" to process each bill, so payment can often take 60–90 days. Then add another step for the secondary insurer's payment. After months of waiting, the patient's balance is typically quite small, making it hardly worth the effort to bill it, let alone pay it. Now consider that most of these bills are being sent to senior citizens, often not in the best of health (not to mention chronic short term memory loss). Also consider that most of these seniors are part of the World War II generation, who pride themselves on paying their bills quickly. I would suspect many of them are overpaying, ashamed to let a bill sit "unpaid" for 90 days.
Information is useless unless it's been collated, edited and packaged for easily access and understanding. The FDA has done a beautiful job of creating standards for the labeling of the food we buy, and the SEC has done it with simplified language in prospectuses. From creating a universal format for information sharing, to establishing consistent software programming, to employing "smart" information systems, to cleaning up the language, the knowledge and the technology exist to make a better Medicare, not to mention a more cost effective one. Employing them is not only crucial for the survival of the system; it's essential for the survival of everyone who depends upon it.
My father is currently in a fourth rehabilitation facility. Miraculously his mind is working better than ever, though he still cannot walk. Much of this is attributed to lying in bed for months without physical exercise. His rehabilitation benefits from both Medicare and his secondary insurer have run out, yet he is not well enough to return home or poor enough to qualify for "Medicaid." And the bills continue to arrive.