Why are docs late? Why can’t I find prices for anything?

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Questions Questin’

Last time, I answered a bunch of commonly asked healthcare questions. It turns out you all have even more common questions, so I wanted to answer a few more I was getting.

• Why is it so hard to figure out what I’m going to pay when I see the doctor?
• Why is it so hard to get my health record in one place?
• Why are doctor appointments always late?
• Why do we drive on parkways and park in driveways?

Shall we begin?

Why is it so hard to figure out what I’m going to pay when I see the doctor?

Let’s use an analogy. Imagine you went to a coffee shop to buy something. But instead of having prices on the board…

1. The price of every item is different based on which credit card you use.
2. To find out what that price is, you need to send the bill to the credit card company and they’ll get back to you.
3. Before you can use a credit card, you need to use $1000 of cash across stores and the coffee shop has no idea how much cash you’ve already used.
4. You don’t know how much coffee you want until you start drinking.
5. The cash register is operating on Windows NT and the cashiers are gossiping about other customers while everything is loading.

Idk if that analogy helped, but this is basically the state of healthcare pricing today. Mapping the above to healthcare:

1. Every healthcare service has a different price depending on your insurance. Most doctor’s offices don’t do a great job of tracking all of those contracts + in many cases the contract isn’t a number but a moving target (% of what Medicare pays).
2. Your health insurance doesn’t make it easy to get that information, often you need to call them or send the bill and find out. Plus we talked in a previous post about how the data standard that payers<>providers use to communicate doesn’t have a lot of the information on what your insurance covers (e.g. the price of a given service).
3. You have a deductible you need to meet each year before your insurance kicks in. For your doctor to know how much to charge you vs. your insurance, they need to know how much of your deductible has already been paid. To figure this out, we need to contact your insurance, so we’re back to bullet 2.

4. There are other coverage rules that apply to all of your provider visits in a given year. For example you might have 20 covered physical therapy visits in a given year. How would your physical therapist know if you’ve used 1 or 21 visits so far? You might have alrady seen other physical therapists that year. You can only know after you bill or contact the insurance.
5. Until the actual visit happens, it’s not super clear all the things you’ll need to do with a patient. Let’s say you go to the doctor to talk about a problem, and during that visit you bring up a lot of issues which then informs the doctor about which tests they’re going to order. The doctor doesn’t know the tests they’re going to order until you actually come in, so how would they know what to charge you upfront?

Now to be clear, other industries have figured this out. For example dental is pretty close to healthcare and has a much clearer pricing structure. They ping your insurance, get the amount of coverage pretty quickly, and then tell you how much you’re going to owe before you get a service. The tradeoff is being told you’re ugly as f*** which a few upsells can fix.

Even in healthcare you’re starting to see upfront pricing, but it requires payers and providers to completely re-architect how they send information to each other and handle contracting. For example, Surest is a plan that only has co-pays and tells you exactly what your copay is going to be + what’s included in the visit before you go. The No Surprises Act is pushing providers to give Good Faith Estimates to patients upfront though implementation is virtually non-existent.

This is the state of healthcare today, and it’s mostly inertia and lack of competitive forces that prevent the industry from giving upfront prices the way consumer-oriented industries do.

[Ironically, thanks to tax and tip in the US I also have no idea what my coffee is going to cost anymore anyway until the checkout screen. Even more American problems.].

Interlude - Courses!!!

We have many courses currently enrolling. As always, hit us up for group deals or custom stuff or just to talk cause we’re all lonely on this big blue planet.

First - our free course on the legal stuff you know if you’re launching a telemedicine company. We’re doing this in partnership with a law firm, if I taught this you’ll telemedicine me from jail.

Sign up to get the slides and recording too, but you wanna show up to ask questions.

Second, we are doing a BETA version of a new course - The Pharma And Life Science Breakdown.

People have been asking us to go deeper into what pharma cares about when it comes to bringing a drug to market. So we’re testing out a course we’ve been developing around it. You can see the curriculum for it here.

We’re doing it at a discount and limiting it to 20 people for this run. You can get it here - ping shruti@outofpocket.health for questions on the curriculum, group rates, etc.

And here are the other courses currently enrolling for next month:

• Claims Data 101 (starts 3/24) - Practical intro to Claims Data
• How To Contract With Payors (starts 3/31) - How to get in-network + negotiate
• LLMs in Healthcare (starts 4/7) - How to understand and deploy LLMs
• US Healthcare 101 (starts 4/22) - The Basics of US Healthcare

You can see all of the upcoming courses here.

Why is it so hard to get my health record in one place?

Sigh, buckle up for this one. 

The first important thing to understand is that most providers are generally disincentivized to give you easy access to your health record. If your data is easy to move around, then it’s easier for you to leave as a patient. This dynamic is not too dissimilar to other products you use - you can’t for example export your social graph from Facebook because that makes it easy for you to go to competitors. Plus, providers can relatively easily get the data from other providers so there isn’t really an ROI to making the patient-mediated approach easier.

Second, here are a few different components when it comes to getting your record.

1. Ownership - who actually owns your healthcare record?
2. Access - how do you actually access your healthcare record? Which parts of the record are accessible?
3. Format - Once you get the record, how easy is it to combine with the records from other places?
4. Identity - how do we know we’re giving the record to the right person?

For ownership…this is actually complicated. Despite data being generated about the patient, the facilities that create the data from doing tests, etc. have ownership over your data. There are some nuances per state which you can see here, but for the most part you don’t actually OWN your record. 

HOWEVER…hospitals do have to give you access to your record thanks to HIPAA. But they don’t necessarily have to make it easy. Hospitals can make you fill forms before they give it to you, charge you fees, or take a long time to get it to you since there’s no mandate it needs to be in real-time. If it’s a paper record, it’ll be a gigantic stack of way too much information. Also certain parts of your digital record will likely not be in there, like diagnostic images for example.

Now what about format? As we talked about in the last installment, the reason fax is still dominant in a world of electronic health records is because of a lack of agreed upon standards to structure and transmit data. So you might get the data on a CD-ROM, or as a stack of printed papers, etc. And you’ll find out that the fields have lots of variation in terms of values, units, and implementation of the fields. 

Just to give you a sense of the scale of variability here, Epic’s public spec for an Electronic Health Information export has 7000+ tables. But that doesn’t even account for variability of values. Even WITHIN a field like labs, you can have a ton of disparate value with different units and results as we show below, an excerpt from our upcoming EHR Data 101 course starting 5/6.

And finally there’s the identity piece. We need to make sure that Nikhil Krishnan - the newsletter author - is the same Nikhil Krishnan that’s in the health records. They might get confused for a New Yorker author that REFUSES TO MAKE A TWITTER SO I KEEP GETTING HIS DMS.

There are different approaches to this - using your credentials to get into your patient portal, signing a consent form with verification, and even using CLEAR (yes the airline social hierarchy company), etc. But each entity will have a different level of security they feel comfortable with before they give the health information out.

All of the above are hoops placed you need to jump through that the hospital is actively disincentivized from clearing up.

As a country, we have not gotten everyone to agree on all four of these components, especially in a digital world. There’s a dance between trying to use regulations to get everyone towards the same goal but also not being too prescriptive on exactly what to do so changes can be made if a new technology comes out, new data needs to be incorporated, etc. Working groups try to fill this gap to create standards and processes, but they’re slow or have different ideological stances on what should be done which can create even more confusion about standards.

As an individual patient, you actually CAN get your records today. It’s just so painful you’d probably rather be in the hospital. You’ll have to call each doctor’s office and you’ll probably have to invoke the name of lord HIPAA and SHIVA. They’ll give it to you after 30 days in some format where you’ll embarrassingly need to buy a “Floppy Disk to USB-C dongle”. Then you’ll try to piece it together with the other records your other hospitals gave in paper binders.

So you can technically get your record - it’s just not easy and takes a lot of time. What most people mean when they ask “why is it so hard to get my record” is actually “why can’t I just push a button to get it into an app instantly?”

There are digital ways to get it. Some companies (Apple Health, HumanAPI, OneRecord, Fasten, b.well) do this by having patients fill out their portal credentials and then succcing up the data into one place. Other companies like PicnicHealth or Citizen Health basically take your HIPAA authority and start bothering hospitals on your behalf to get your records, which they then digitize for you at a cost. 

But all of these methods have shortcomings in the data they’re able to get, the timeline they can get it, or that some providers just make it as hard as possible. To top it off, enforcement is spotty. 

There are new attempts to make this process easier. For example the 21st Century Cures Act aims to penalize hospitals that make it hard for you to get your record, set the data standard and types of data that need to be available, push for more standardized APIs, and make certain parts of your record available in real-time with the rest in a reasonable time frame. But there’s still so many open pieces around enforcement, identity verification, etc. 

There are other methods brewing to make it easier for apps to get patient data with their consent like TEFCA, an area so niche a tumbleweed actually blew by my computer as I typed it out. But I very strongly recommend watching Brendan Keeler’s talk on this to learn more - he goes through all the current attempts to make it easier for patients to get their data and the pros/cons of each method.

This problem can be solved though. When a boom of fintech apps like Venmo came out that consumers wanted to use, consumers needed to connect their banking data to them. Banks also didn’t love making their data easy to pull and the process for connecting to them was annoying/difficult. Plaid came out which essentially used user credentials to screen scrape and pull out your bank data. Banks then had their hand forced and made it easier/more secure to have your data move through Plaid. Today you can pretty easily get your data out of any bank and use it in third-party applications.

However, this dynamic only exists because banks very actively compete for customers. If a bank doesn’t work with Plaid now, customers can pretty easily move to a bank that does. Unfortunately I’m not convinced that this problem is going to be solved in healthcare until hospitals actually have to compete to attract patients. 

Why are doctor appointments always late?

I’m writing this after getting back from an appointment that was 30 minutes late. If I had a real job this would be a serious issue! How theoretically inconsiderate!

It’s actually pretty hard to optimize a doctor’s schedule. There’s a lot of factors that contribute to this:

1. The visit duration isn’t predictable. Let’s say a patient comes in and gets their issue addressed. But then they start talking about another issue despite their time being up. “I’m just here to get my labs done, btw I want to kill myself”.  Most docs aren’t going to kick the patient out and say make a new appointment for that. There’s a whole variety of issues that add variability in the visit time: complications, making sure the patient understands the instructions/diagnosis, emergencies, etc.
2. Hospitals/Doctors will tend to overbook their days (e.g. have some patients with overlapping times). This ensures that if there are any no shows during the day, then the office is still running at max efficiency. But sometimes all the patients actually come or patients run late or patients with urgent needs show up. This inevitably leads to spillover in the schedule.

3. Patients basically never walk out because of the wait. The reality is that if the next appointment is weeks/months out, you’ll probably whine to your spouse when they ask how your day was but you’ll still wait. These are the downsides of a system where there aren’t true competitive forces.

Most doctors don’t love that patients are waiting either - in fact many are fine with no-shows so they can use that empty time to catch up on patient notes/answer uncompensated medical texts from friends. But most doctors also work in settings that emphasize productivity, and the number of patients seen is a big component of that. The reality is that more total patients are probably seen per day in this system, even if they have to wait.

[I will say that I’ve never had wait times of more than 5 minutes as a One Medical member - so it’s clearly possible operationally. But One Medical probably has a less complex patient population and is literally selling the experience, so they’re incentivized to make that happen.]

Parting thoughts + Headhunting

I like getting these questions because it actually forces me to revisit basic problems in healthcare, and they might be more solvable today thanks to things like AI, cultural shifts, etc. It’s like some industry specific horseshoe theory where a question is so basic it becomes interesting again.

So send me your random healthcare questions, I’ll try to answer more of them.

Quick plug, we’re helping more companies with their hiring. Right now looking for the following at different early-mid stage companies:

• A founding operations specialist
• A clinical specialist
• A product manager
• A head of design

Fill this out and we’ll connect you if it’s a fit.

If you’re hiring a bunch, let’s chat about options. No commitments, very Zillennial. We just had an excellent VP/C-suite medical candidate join the pool + one of the strongest biz dev people I know is on the market.

Thinkboi out,

Nikhil aka. “FAQS machine”

Thanks to Brendan Keeler and Phil Ballentine for reading drafts of this

Twitter: ​@nikillinit​

IG: ​@outofpockethealth​

Other posts: ​outofpocket.health/posts​

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