Monday, October 28, 2019

Mission Impossible Part I

Thanks for nothing!
A personal rant on system thinking


This is a rant –I hope a higher-level one – about healthcare customer service, “service” we all endure just by being self-insured and/or Medicare clients.  As I hope my ongoing Cultural Intelligence blog is showing, I’m a reasonably educated person, having served as a consumer reporter for a Philadelphia newspaper, and an investigator of group behavior and the social mind.  If I’m having this kind of difficulty in dealing with routine healthcare, I shudder to even imagine what less well-equipped patients (and their families) are enduring.   So I’m judging that if I’m having this much trouble, others must be, too.  (Part II talks about customer service state of the art as the broader set of issues.)

I’m closing in on the 125th hour (all unpaid) of trying to get ordinary patient information from my prize-winning national-reputation healthcare organization in Philadelphia.  At some point, as a new patient, it occurred to me to actually research their mission – in just three words, “We Improve Lives,” the pledge to make my life better.  So far, it has done the opposite: by chewing up my work schedule, domestic tranquility, and sleep, and indeed making my healthcare mission an impossible journey. By forcing me to repeat-call many offices, very few of which call me back.  Then it’s back in my court to begin again the next day, telling my war stories over again to whatever office or functionary will listen.  I’m in constant contact with the Billing office, the Rheumatology department, Internal Medicine, my primary doctor, and three other specialists.  I have insurance through Medicare, but they seem to be less than able to help me out in my dark quest around the medical campus in search of answers.  All this effort is just in the service of trying to understand the system’s errors as these affect me.  My health is actually fine.  At over 65, I am interested in keeping it that way by following a solid screening schedule.  For the very sick and injured, this bumpy ride through the healthcare system has to be an unimaginable unmanageable nightmare. 

First, as one of my colleagues, a psychiatrist, put it, these days medicine is an inherently defensive practice.  So just contacting anyone is a tricky wicket.  At the other end of the scale is the mandate of Patient Rights, which you would think would open up dialogue everywhere on every topic of concern to patients.  I assumed the patient was at the center of any practice and the whole organization (again, this headlines the hospital’s home page: "People First").  But acting as my own advocate over the past three months has shown this to be a weak philosophy in practice.  Across the many offices and practices where I’m becoming notorious is great variability in how I’ve been treated and regarded – almost as if they have no relationship except payroll and signage.  The fact that these entities consider themselves almost sovereign states for policies and accountability reflects the problems of all organizations without a strong cultural ethic.  Or, it seems, accountability for their attitudes and actions.

The patient rights issue is probably central to explain my continued suffering.  I trust this parallels the human rights movement.  My review of this policy: 80% of all statements refer to hospital in-patients, while I’m an outpatient only.  When I pointed this out, the Patient Experience office told me that this hospital-based policy is nevertheless applicable to every patient type.  I have difficulty seeing how smoking policies and nursing care have any relevance to getting information from a busy front desk at the billing office.  My questions are around why I’ve been billed twice directly as a first-person (self-pay) case, when my insurance should be billed first, me second.  I had a horrified period when the first bill arrived by mail and I had to assume my insurance had denied payment.  It took a week just to get Billing to call back to explain that this was a back-office computer error that had happened not just to me but many other patients.  Nevertheless, there was never anything like a notice to give those affected a heads-up that this error had occurred.  When two months later the same thing happened in exactly the same way, I wondered how much my healthcare had paid for this terrific new “integrated” EPIC program that couldn’t bill properly.  A search on the internet under the EPIC name confirmed that millions are being spent in fixes across the healthcare landscape for this programming.

When I went up the ladder into the third month of this malfunction, I got a curious response:  the billing VP said he was going to be honest about the mistakes made.  Apparently this approach did not include any notice to anyone.  I tried to explain system theory to him – systems have their own dynamic of reward and punishment, or inattention and denial – regardless of the moral character of those who live and work within it.  I don’t think he paid much attention to anything I said.  The ethic seems to be to get through any discussion asap, asking along the way, “Is there anything ELSE I can do for you?” establishing the fiction that anything at all has been taken care of. 

Time and again the agents for the organization would insist that their efforts were genuine and that they were doing their best job under the pressures of an ever-expanding healthcare empire.  That’s not possible to prove or disprove, and it does nothing to help the patient find out what is going on—with charges or with outliers like security breaches. Two phrases are the litany of customer service: “I don’t have any idea,” and “You will have to call ____ office for that.”  I am often misdirected to inappropriate people and places, costing additional time--and always added frustration--for all parties.

Soon after the “system theory” came up, I received several lab test orders by mail.  I assumed they were all mine, until I was ready to walk over to the Outpatient Lab.  (No office seemed to know any room numbers within the large medical building where the lab is located – I had to physically research and inform the organization of the exact room number.)  I noticed I had, not my own, but another patient’s name, date of birth, patient account number (patient ID is actually a billing code), full address, and a list of ordered tests. 

This is called a PHI privacy breach.  What is the first thing any patient thinks of when they get someone else’s record?  It’s “Where is MY record, why did I get someone else’s, and what happened to breach my right to patient privacy?”  Many hours and calls later, I am still trying to find out, but this is at least considered serious enough to send to the Privacy / Compliance office.  That manager is out sick for awhile, so I need to wait a week or more to find out what the drill is to get that sorted.  Meanwhile, if my lab order (which I never received) is out there with another patient, I hope they don’t have criminal intent.  There’s quite enough of my personal information there to open bank accounts and much more. 

Finally talking with the practice manager in charge of said information, she was notably focused on getting the wrong patient order back in her hands.  I reported that the lab had confiscated it when I showed it off (and caught the fact that it was not my order, a fact I wanted to confirm for myself).  When I asked what had happened to my information, everything was done to dismiss my interest in the privacy breach—as personal opinion or hopped-up anxiety.  And then the topper – “I’m sorry you feel that way.”  This is the Number One Phrase to Never Say to a Patient.  I had a rare laugh to hear that coming from a practice manager.

I don’t think HIPAA will take that view – at least, I expect vigilance to be more active higher up.  I was shut out of any emails I could use to send a list of the normal clarifying questions to find out how the practice handles such security breaks.  Meaning I am going to be forced to walk the document over to their offices myself.  And have it signed for at Reception. 

Meanwhile I’m without answers on either issue, and seriously wondering what has happened to patient care, and whether the same clutter, obfuscation, and confusion is reflected on the clinical / medical side, where it could do real harm.  The Hippocratic Oath, Do No Harm, still rules the practice of medicine.  It’s just that patient care doesn’t know about or adhere to it.   So where is Quality Control and Standard of Performance in all this mess?  No one ever mentions them.  Why not?  Because there is no comprehensive way of dealing with these standards.  Yet it’s very clear how absent they are, and how much leadership needs to do to begin to grapple with the service fundamentals. 

Above all, however, medicine is now all about the UX or user (patient / client) experience, as is all else in the emerging world of the Experience Economy.  And yet service is worse, costs are higher, and answers are harder to come by than ever before.  It is astonishing how much verbal punishment and time abuse attends just trying to find, understand, and fix the system’s problems – not caused by patients, but left to them in order to hold their own healthcare services together.  Of course medical staff is paid to answer my questions and fix breaches in billing and privacy; I’m not.  Yet my sources for damage control are disconnected, siloed, largely uninformed outside their own m├ętiers and titles, and often within as well.  I’m calling it patient hazing.  It violates my rights across many aspects, from simple policy requests to holding me responsible (on the “MyChart” website) for big bills my insurance should pay.  I’m thinking hard about whether I want to sign again next year.  The problem is that I just changed over all my providers, including my primary doctor, to this system – if you have ever had to endure this, you know that no one really wants to repeat this process, much less twice in one year.  (This transfer was the outcome of insurance changes, not any issue with my former plan, which covered another hospital center.) 

Now, you must be thinking – haven’t you tried to contact the Patient Advocate?  Of course.  There just doesn’t seem to be one, or it remains disguised under another title, or their office doesn’t return calls.  So, with my growing file folders of notes and documents I’m constantly generating to document my encounters and clear up inconsistencies and fill gaps…I’m heading into my 125+ hours in the coming week (and maybe this weekend), as a lone advocate for myself.  I really wish I knew who had my back, but I think I can safely say that to the system I’m Patient Zero in a whole new sense.  And this is one of the country’s leading-reputation centers.  What are things like in rural areas with less money, fewer high-end specialists, skilled nurses, and billing clerks? 

Probably better, would be my guess, because people at least have some chance of knowing one another, other departments, how they operate, and the System may have an intelligible culture.