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With traditional insurance claim processing, how often are claims rejected?

The last time we looked at the outside world, about 33 percent of claims did not go through on the first try. And they had to be redone some number of times. I think it was 2.6 cycles of claims per encounter.

Imagine the impatience, the frustration, and the sheer costs associated with that.

We’re now below 5 percent of claims that need to be rehandled.

Do you benefit from the complexity and opacity of the U.S. health-care system?

We call it “The Beast.” Every doctor goes through life with this slight prickle on the back of her neck that there is a giant black primordial octopus whose tentacles are connected underneath the desk and in the exam room and in the file room and it’s slowly kind of wrapping these tentacles around their life and crushing. Whether they make a million dollars a year or ten dollars a year, they all have this sense of being crushed by some mysterious force that is outside of their control and that does not have a heart.

Why is the system so perverse?

These rules were all the well-intentioned campaigns of some congressman back when some mobster in Brooklyn did too many mammograms, right? And now all these rules, these never-let-this-happen-again laws, have piled up in the bottom of the doctor’s file room and it’s just almost impossible to breathe. It’s impossible to get excited about moving your practice to a new place, a new metaphysical place. What we are doing is taming that beast.

You don’t think President Obama’s health-care reform will reduce the complexity in the U.S. health-care system. You believe it’s just going to increase the complexity?

Look, a system can be complex but beautiful. The most beautiful systems in the world—like biological systems, or retail supply chains, or equity trading markets—run more cleanly and sophisticatedly than many others. These systems that we take for granted are insanely complex: probably a lifetime can be spent studying them, and you’d still not understand them. We’re calling this health-care reform, but it really looks more like one of Mao’s five-year plans: a “great leap forward.” It is a conscientiously-thought-through set of improvements, but they’re conscientiously thought through by a central authority that is going to force everyone to comply. So the natural forces that keep complex systems running smoothly will not be in play, and you’ll end up with these Kafkaesque moments. Any system with so many players that is inflexible, unresponsive, and carries the force of law is going to create unfortunate side effects that won’t go away.

Technology helped increase the costs of health care. Is technology part of the solution in bending the cost curve and controlling costs, too?

The first thing that technology can do is tame the Beast. But then, technology can be used in more creative and subtle ways. Doctors are the people who are doing Pap smear samples on women to screen for cervical cancer—$250. Absurd, right? Doctors are doing routine surgeries that would be much better done by a technician whose only job is to execute that one surgery, like we’ve seen with eye surgeries. But all of that will require a level of process control. Today, we don’t have a healthy technology system around process control. We’re the first player in that, but there’s going to be others now that the cloud-based business service model exists. We expect to see lots more competition.

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Credit: Athena Health

Tagged: Business, Business Impact, business, EmTech2013, The Era of E-Medicine, AthenaHealth

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Jason Pontin Editor

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