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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,
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
“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
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
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
Bason questions the role designers will play in the reshaping government in the future, and why anyone who wants to make wide-reaching social change should brush up on their management skills.
Section: Inspiration -
Conference , government, professional development
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