An Inside Look at Healthcare
Over the last eight years, I’ve written approximately 100 columns for Human Resource Executive®. While the topics have run the gamut, I’ve spent the most time thinking about the moving target we call healthcare and health insurance — much like most HR and benefits leaders.
This column once again considers that topic, but the twist this time is that I based my thoughts upon a recent personal experience: For the first time in my life, I agreed to undergo a hospital-based procedure that also included an inpatient stay. I closely followed the process and, similar to the learnings I took away after being struck by a car, I gained new insights into the successes and pitfalls of healthcare today.
What follows are the seven things I learned.
1) The ongoing debates regarding healthcare are changing healthcare practices. My surgery was not based upon addressing a serious or life-threatening condition. In fact, there was an optional element as to whether I needed the procedure. I generally knew, however, that I would most likely need to address the situation in the future. But the rhetoric over the last couple of years regarding health-insurance design drove my providers to recommend that I have the surgery now. Their concern for me and other patients was the potential return of some form of pre-existing condition exclusions and/or insurance caps, which most likely would result in a claim denial were I to wait.
2) Choosing the best health plan for unexpected needs. Long before I worked in healthcare, my parents preached the importance of choosing medical insurance that would allow us to be treated by the highest quality physicians and medical facilities — should the need arise. They espoused two premises: insurance was meant to cover the unexpected bumps in the road, and there was nothing more important than your health.
I carried their advice with me throughout every benefit selection I made. During the last open-enrollment period, I chose the only PPO option offered that provided coverage for out-of-network physicians and facilities. All my other choices limited medical care to my home state and in-network physicians and facilities.
As a result, when I found that the best surgeon for my procedure was out of state and out of network, I maintained the ability to select him (at an overall out-of-pocket cost of just under $20,000).
3) Selecting the best hospital doesn’t always guarantee your chances of a good outcome. I am a big fan of Leah Binder, president and CEO of The Leapfrog Group, an organization dedicated to providing consumers and employers with transparent information about hospital quality.
I searched through the most recent hospital ratings and found one A-rated,” in-network hospital. It was a nationally known facility, and it had one surgeon trained in the procedure I needed. But I didn’t choose to go there.
I’m fortunate to have a broad network of highly regarded physicians who also happen to be friends and colleagues. I learned through them that there is wide variability in the initial success of the surgery I needed. The physician associated with the in-network facility had a 30 percent failure rate” — meaning corrective surgeries were needed for a third of his patients. I also discovered that this failure rate was relatively common among surgeons across the U.S.
With my friends’ assistance, I chose instead a surgeon associated with an A-rated, out-of-network facility whose outcomes had less than a 1 percent failure rate.
4) Health insurer’s decision support tools and nurse support line do not always live up to their advertising. I attempted to use my insurance carrier’s quality-rating tool for both healthcare facilities and physicians. I found it to be woefully inadequate. The Leapfrog Group provided current information with much greater detail.
The insurer’s rating of physicians was only available for in-state providers and didn’t yield any critical information, such as surgical failure rates.
I chose to give the health insurer one more opportunity to assist me. I called the nurse support line. I worked my way through the automated voice support and was instructed to leave a message with the usual information — name, policy number and date of birth — as well as when I was contemplating surgery and the best way to reach me. Options were given for calling me back in the morning, afternoon or evening. I provided the ideal timing for the surgery and my mobile phone number, requested an evening call any time after 7 p.m.
It took a while, but I did receive a phone call — on my landline phone, in the morning — and several weeks after my surgery.
5) Sometimes, patients need family support to successfully recover. In addition to my surgeon’s success rate in the operating room, the other reason I selected an out-of-network physician and healthcare facility was the fact that both were located close to my family.
My physician’s surgical recovery plan included several elements. He and the hospital used an enhanced-recovery-after-surgery protocol that allows patients to resume normal activities more quickly and with fewer complications. While the insurance company approved a seven-day inpatient stay for my procedure, my surgeon discharged me after three days.