Look at the statements of Donald Berwick and that is exactly what he is talking about.
We could even look at some of his papers.
The 100,000 lives campaign: setting a goal and a deadline for improving health care quality
What Practices Will Most Improve Safety?
On the trail of quality and safety in health care
The Business Case For Quality: Case Studies And An Analysis
Measuring Physicians' Quality and Performance
The Triple Aim: Care, Health, And Cost
Wow, interesting to see one of the country's foremost experts on quality improvement and patient safety write so much about quality improvement and patient safety.
The simple fact that there had to be waivers and exemptions immediately after the bill was passed should have been enough to tell us that it is a piece of crap bill.
Do you think if annual limits in health plans weren't being phased out it would be a good piece of legislation?
I did not make it up Greenbeard. The Link affirms everything you denied was in it.
No, it doesn't. That's my point. The argument, poorly formulated as it is, seems to be based on two things:
1) The electronic standards are to, among other things,
"enable the real-time (or near real-time) determination of an individuals financial responsibility at the point of service and, to the extent possible, prior to service, including whether the individual is eligible for a specific service with a specific physician at a specific facility" and
"enable, where feasible, near real-time adjudication of claims ...". Judging by the use of bold in the article, that second one is particularly important (as is use of the word "individual").
2) The second part seems to be the real crux of it:
In fact, this is so clearly defined in the bill, that on page 64, the language for "operating rules" (which regulate the "using and processing [of] transactions") is changed in a related section to add the phrase "on behalf of an individual." Combine the two, and you have the government paying for services on behalf of an individual from the individual's account.
The author has clearly drawn a conclusion, yet it makes no sense and doesn't follow from anything else that has been laid down. "The government" hasn't even entered in the equation (beyond Medicare adhering to the same standards as everyone else when it pays claims), as this is about electronic communications between private insurers and private providers. Nor has any individual's bank account. The text references private insurers making payments on behalf of individuals, which I take it is supposed to be the scary, offending piece of the puzzle--
except that's what private insurers do. They pay all or part of the clam for you.
I can't really grasp how this is supposed to be contorted into the government (not mentioned in the text) accessing your bank account (not mentioned in the text), but I don't think that's a failing on my part--that article is really just argument by innuendo. There's no there there.
Let me give you a very simple example of what these standards would have been for. A few months ago, I had some dental work done. As I was leaving, the admin person estimated what my share of the costs would be and I paid it. Several weeks later I received a letter from my insurer in the mail showing the value of the claim submitted by the dentist's office and the portion that had been reimbursed by the insurer. Lo and behold the difference (my share) was actually smaller than what I had paid on the day of the visit. Which means I then had to wait a few more weeks to get a check from the dentist's office correcting the overpayment.
Now, in the 21st century it's entirely possible for that process to take place in closer to 6 minutes than six weeks, avoiding the initial overcharge of the consumer (me) in the first place. That requires the information systems of my provider and my insurance company to speak to each other real time.
What would they be communicating about in my case?
Well, first my dentist's admin people wouldn't give me an--ultimately incorrect--estimate of my share of the costs, they would communicate with the insurer in real time and tell me exactly what I personally owe (
"enable the real-time (or near real-time) determination of an individuals financial responsibility at the point of service"). That eliminates the annoying initial overcharge and the wait-for-the-reimbursement-check-to-come-in-the-mail delay.
Of course, stepping back a bit, I might have needed to verify that my insurer would pay for part of the dental work I got and that my dentist is or still is in my insurer's network (
"enable the real-time (or near real-time) determination of [...] whether the individual is eligible for a specific service with a specific physician at a specific facility"). If I needed that done, it would be great to have it verified in real-time on-site.
But now the work is all done, the admin folks have charged me the correct amount (which
I still pay for out of
my account). However, it still remains for my insurer to pay my dentist its share, which could take a few weeks. Now, as an individual, I don't care so much about this part because it's between the dentist and the insurer but they sure care about it. Imagine if they resolved it over the course of a few minutes instead of over the course of a few weeks of exchanging paper related to the insurance claim (
"enable, where feasible, near real-time adjudication of claims ...").
Of course, in my case I
did care about this because my financial responsibility for those services wasn't determined in real-time and thus wasn't calculated correctly--thus I had to wait for the insurer-provider reimbursement process to occur, and then I had to wait for additional time beyond that to get my money back from the provider. Granted this is a somewhat trivial example that pales in comparison to equivalent situations in which someone is receiving actual medical care (no offense, dentists!). But I hope it gets the point across.
Allowing this real time communication between insurers and providers to allow things like the real-time calculation of my portion of the tab and the amount the insurer will be charged (yes, on behalf of me, the individual) requires uniform standards for the information and financial transfers, in large part to make sure my information is protected.
But none of this involves anyone, including the government, going into your bank account. Do you see what these standards are for?
