Stop squeezing the cost balloon but instead take the air out. In the US, more than one quarter of every dollar spent in healthcare is for administrative costs, a number that far outpaces every other nation. We have become overrun with well-intentioned checks and balances that each attempt to solve a problem but together have created a massive administrative burden for healthcare providers. For example, when a valuable but expensive test is invented, insurers ask additional questions to ensure the test is appropriate. To prevent fraud, physicians have to document additional information to demonstrate the care provided and amount charged is appropriate. Together, all of these additional asks on healthcare providers add substantial additional work for the caregivers and their staff and require new investments for solutions and processes to address the regulatory burdens. We take cost out of one area and yet add new costs and frustrations to other areas in the process. The change I would make (albeit easier said than done) is to focus the majority of the regulatory bodies’ resources on reevaluating and reducing all of the regulatory burdens. Each administrative burden should be judged critically based on the overall societal value vs the burden to the provider, the healthcare staff and patient to identify every single opportunity to eliminate or simplify work that does not directly improve a patient’s care or care experience.
Ihad the pleasure to interview Andrew Mellin, MD, MBA, the VP of Medical Informatics at Surescripts. At Surescripts, Dr. Mellin is focused on helping the Surescripts Network Alliance improve the patient and pro vider experience using Surescripts’ solutions for electronic prescribing and healthcare information interoperability. Dr. Mellin is trained in Internal Medicine and has over 20 years of experience in health information technology for providers, patient quality and safety, and consumer health at McKesson, RedBrick Health, and Spok. In addition, Dr. Mellin led the provider engagement team at Allina Health in Minneapolis for their EHR implementation at 8 hospitals and 60 clinics and worked part-time as a hospitalist in St. Paul, MN, for 15 years.
Can you tell us a story about what brought you to this specific career path?
I went through physician training when the Internet was just becoming relevant. Even then, I knew I wanted to become a trusted advocate and enabler for the caregivers who were trying to provide the best care to the patient, for the technologists who had amazing tools that help caregivers make better decisions, and for the business administrators who were managing the opportunities and constraints in healthcare. I wanted to speak the language of each of those groups and bring their diverse perspectives together to solve incredibly challenging problems. Since then, I’ve realized that as part of a technology company with broad national reach, I can have a much bigger and more positive impact on a provider’s work experience and patient care than I could have as a practicing physician.
What do you think makes your company stand out? Can you share a story?
I’m proud to be part of a team that has not only built the technology that has markedly increased the safety and quality of virtually every prescription written in a clinic and sent to the pharmacy, but more importantly convenes the entire healthcare marketplace to solve extraordinarily important challenges for American consumers. For example, over the past few years, we tackled an important aspect of medication cost — helping providers and patients know the out of pocket cost of medication before a prescription is written and displaying less expensive prescription alternatives, all without having to leave their prescribing workflow. To solve this, we needed to create a common way to deliver this information from insurers to electronic health records, and this is now available to more than 135,000 providers. The response from the providers has been incredibly positive — they are saving their patients money and saving themselves and their office staff time. For example, when presented with lower-cost alternatives, prescribers using this technology save their patients an average of $88 on blood glucose lowering medication (excluding insulin) and $105 on antidepressants. Among specialists, the average cost savings per prescription ranges from $228 for psychiatry and $69 for obstetrics and gynecology.
What advice would you give to other healthcare leaders to help their team to thrive?
From the perspective of being a healthcare leader in a technology company, I always remind my team that we are fortunate that our work has deep, important meaning, and that they, or one of their loved ones, may personally rely on the technologies we are creating to restore or maintain their health.
My best days are when I share stories about how our solutions improved a person’s health and healthcare experience. At the same time, these stories remind all of us that our standards are much, much higher than virtually all other industries. People’s lives truly do depend on what we create, and we should never compromise on safety, reliability, and trust.
You are a “healthcare insider.” If you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
1. Stop squeezing the cost balloon but instead take the air out
In the US, more than one quarter of every dollar spent in healthcare is for administrative costs, a number that far outpaces every other nation. We have become overrun with well-intentioned checks and balances that each attempt to solve a problem but together have created a massive administrative burden for healthcare providers. For example, when a valuable but expensive test is invented, insurers ask additional questions to ensure the test is appropriate. To prevent fraud, physicians have to document additional information to demonstrate the care provided and amount charged is appropriate. Together, all of these additional asks on healthcare providers add substantial additional work for the caregivers and their staff and require new investments for solutions and processes to address the regulatory burdens. We take cost out of one area and yet add new costs and frustrations to other areas in the process.
The change I would make (albeit easier said than done) is to focus the majority of the regulatory bodies’ resources on reevaluating and reducing all of the regulatory burdens. Each administrative burden should be judged critically based on the overall societal value vs the burden to the provider, the healthcare staff and patient to identify every single opportunity to eliminate or simplify work that does not directly improve a patient’s care or care experience.
2. Give every patient an expert to help guide their healthcare journey
I’ve had a few significant, personal interactions with healthcare over the past year. Fortunately, none were as challenging as others have experienced, but in each of these interactions I know my knowledge about healthcare changed the way I experienced my care. I felt I was able to be a partner in the decision processes with my physicians and not be a passive patient, and I was able to advocate for myself when I felt I was not getting the care I needed. I am in the small minority of patients who have that type of background, yet as a human being these moments are scary and having a guide and advocate is invaluable.
While I know some health systems and providers are working hard to provide a better overall experience and demystify the care process, every person should feel confident that they are fully informed, are sharing in the decisions, and are receiving the care that is completely aligned with their values and personal beliefs.
3. Restore joy to caregivers
When 44% of physicians say they feel burned out, you know there is not just a problem but a crisis.
As I talk to my physician colleagues, many of them wish they could change careers but feel trapped as there are few alternative professions they could undertake at this point in their life. They love caring for their patients, solving the hard clinical challenges, and working with their colleagues, but the administrative burdens, the hours required to finish their non-patient care work, and feelings of loss of autonomy are overwhelming. I think all of us want to receive care from a physician who is focused on the patient in front of him or her and not encumbered with work fatigue, frustration and worry.
There are no simple fixes; health systems are putting in place Chief Wellness Officers to focus on this problem and healthcare leaders are directing substantial energy to finding solutions. While the halcyon days of simpler medical care are long gone for providers, we must remember that we all will depend on an engaged, focused provider when it is ourselves or our loved ones who are ailing.
4. Make it easy for the caregivers to do the right thing
It is nearly impossible for a physician to keep up with the latest in medicine while remembering to complete every evidence-based task for a patient’s care.
While electronic health records have made it far easier to retrieve relevant patient information compared to paper charts, we are still in the infancy of providing true cognitive support for caregivers.
As a consumer, when I have a decision to make, Internet search engines have an almost uncanny way to predict my question and provide the answers that I need quickly. As a provider, in the context of a 15-minute visit, I face the impossible challenge of recalling all of the latest recommendations, being a perfect diagnostician, and completing every evidence-based task.
While the final care decisions should always be personalized to an individual’s preferences and validated by a physician, we are starting to see real world impact of technologies like artificial intelligence that truly augment the human physician’s ability to find obscure patterns of disease and to choose an optimum approach to therapy.
5. Give every person an equal opportunity to restore or maintain health
Nobody wants to be sick, develop cancer, or suffer from a major chronic disease. Yet, depending on age, race, location, gender identity, socioeconomic status, and many other factors, our personal ability to receive quality care will greatly vary. There are many points of view on how to address this issue, yet when we don’t address these disparities we all pay the price — people show up sicker to receive treatment, use places like the emergency room for care because they don’t have access to primary care physicians, and die earlier with conditions that could be managed. We pay the price in economic costs when people can’t work, and we all pay the price with higher insurance rates to care for sicker patients who don’t have ready access to healthcare. This price is massive — to the tune of over $130 billion for both causes every year. Quality healthcare can’t just be for the privileged and fortunate. Quality healthcare should be accessible for all.
How would you define an “excellent healthcare provider”?
There is no shortage of exemplars of excellent healthcare providers. They were my mentors and role models as I trained, and I’ve been fortunate to work with many of them in a community hospital when I worked as a hospitalist.
To me, there are five characteristics that are essential:
- First, the provider must be outstanding clinically and technically — up to date on evidence-based care, meticulous in procedural techniques, and thorough in critical decision skills for identifying potential diagnoses and choosing diagnostic and therapeutic options.
- Second, the provider must have empathy. The person sitting on the exam table or lying in a hospital bed is a human with hopes, dreams, concerns and fears, and the provider has to have awareness and consideration of what that person is feeling.
- Third, the provider should value, trust, and utilize the entire care team. The provider is not the “captain of a ship” barking orders; rather the provider is a leader of caring team of individuals that together helps the patient restore health and navigate the health system.
- Fourth, the provider should embrace shared decision making. Each choice in healthcare — diagnostic options, procedures, medications — has a set of risks and benefits, and the choice should be made in a collaborative manner that incorporates the patient’s and provider’s knowledge and the patient’s values to choose the best path forward.
- Finally, the provider has to simply be nice. Providers have good days and bad days and have a wide range of personalities, just like any group of people. Yet a provider’s job is to provide comfort, knowledge, and healing to the patient and their families in a time of need, and provider’s the emotional state, attitude, and treatment towards the patient and others can go a long way towards creating a supportive environment and a positive care experience.
Are you working on any exciting new projects now? How do you think that will help people?
One project I’m really excited about is our ability to show the physician the patient’s exact price of a medicine while the physician is prescribing the medication. There are very few times in life where you commit to purchasing something without knowing the cost, yet that is the way most of us experience the surprise when we pick up a medication at the pharmacy.
As a physician, of course I want to choose a medication that offers the best chance of improvement at the lowest cost for the patient. But that information was truly unavailable in the past. I could make a guess based on past experiences or if the drug was on formulary, but I would have no idea what the patient would pay at the pharmacy counter. When the optimum choice is not made, at best the patient pays a few dollars more than they should have; at worst, the patient shows up to the pharmacy and, upon hearing the price, makes the hard decision to not get the treatment. Studies have shown that patients are 4.7 times more likely to not pick up a medication when it is over $50 compared to when there is no copay.
Over the past year, my colleagues and our partners in the Surescripts Network Alliance have created and started to deploy a new way to not only show the physician the out-of-pocket cost for a medication for the patient but also show less expensive alternatives that can likely achieve the same clinical outcome. The lower cost alternatives may be receiving the medications via a mail order pharmacy, prescribing a three monthly supply instead of one month, or choosing a similar, therapeutically equivalent medication. This information is shown to the provider as soon as the information is entered into the electronic health record, and the provider can quickly choose the less expensive alternative if appropriate.
What is also exciting is the stories where providers are showing the screen to a patient and having a collaborative discussion to choose the best option. We are starting see great results — savings of $10s, $100s, or even $1000s of dollars for a prescription. What physicians are telling me is that this is the type of capability that helps fulfill the promise of electronic health records — obtaining information they never had before, showing it in the context of their existing work, delivering it in a way that improves a patient’s experience and outcomes, and reducing the extra rework by them and their office staff.
What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?
I’ll share a couple of the resources that inspire me.
I’m rereading Atul Gawande’s book “Being Mortal.” I think we all wish our bodies were a bit like a car — when something breaks, fix it. When a joint goes bad, put a new one in. When you get an infection, give antibiotics to eliminate it. When you get cancer, cut it out. Dr. Gawande’s book reminds me, and all of us, that despite the amazing progress in medicine, sometimes less is more. Our job as physicians is not to do everything but to do the right thing for each patient aligned with his or her hopes and values. The right thing is an honest, compassionate discussion with the patient and the family and, where appropriate, choosing to focus on nothing else beyond supportive care to allow the patient to enjoy the highest quality of life possible. And that discussion can lead to a far better experience for the patient and family during difficult times, allowing the person to actively participate in precious moments and important life events, living longer, or dying at home surrounded by loved ones instead of in an intensive care unit. As physicians and as a society we have to have the challenging conversations about realistic expectations and each patient’s core values and accept that we cannot always fix everything, which is often much harder than just trying another treatment.
I also enjoy listening to the podcast “How I built this with Guy Raz.” He interviews founders of businesses across many different industries who have been very successful. Not only am I inspired by their insights to find the right idea, their hard work, their struggles, and their successes, but I also appreciate their humility that their dreams were nearly derailed many times but their passion, their family and colleagues, and sometimes “creating” the right lucky break ultimately led to their success.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger.
I’ve always been inspired by Don Berwick and the Institute for Healthcare Improvement. In 2004, he created a bold initiative to “save 100,000 lives over 18 months” and in retrospect he created a movement that far exceeded that ambitious goal. If there are about 1,000,000 active physicians in the US, 44% are reported being burned out, and 78% are experiencing some signs of burnout, let’s set a goal of restoring joy to the practice of medicine to 500,000 physicians in five years.
This goal isn’t simply to improve happiness of physicians; this goal is to ensure all of us receive best healthcare experience and the highest levels of safety and quality of care as burnout negatively impacts the way providers deliver care. As a society, we all have to recognize that we have a stake in ensuring the physician workforce is engaged, focused, and passionate about providing great care. We must create a work environment for providers that is satisfying, balanced and meaningful, is supported by a well-oiled team and community, and is virtually free of the ongoing, non-patient care related frustrations and burdens that ultimately wear the physicians out.
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