On Tuesday August 19 at 9:15 AM, Dr. Gabriel Sanchez and Dr. Melanie Sonntag of the University of New Mexico's Center for Social Policy will present the Legislative Health and Human Services Committee (LHHSC) with the dramatic results of a recent analysis of the medical claims and billing system of New Mexico.
The meeting will take place at UNM-Gallup at 705 Gurley Avenue and the webcast can be viewed live or recorded by going to nmlegis.gov and clicking on "Webcast."
This groundbreaking study asked New Mexico health care clinicians and claims professionals directly about their experiences with billing and insurance-related tasks and their impact on cost, patient care, and morale. It included medical and office staff from a variety of health care settings in both urban and rural counties.
It found that the revenue cycle is time-intensive and complex, with many participants blaming it for compromising care and driving health care workers out of the field.
"In medical school, we learn evidence-based medicine," said one clinician. "In residency, we learn systems – and insurance – based medicine and often, those are two very different things."
Each private insurance company and public payer covers different drugs and procedures with different requirements to justify these treatments – and constantly changes these requirements.
According to the authors Dr. Melanie Sonntag and Dr. Gabriel Sanchez, clinicians reported spending at least 3–4 hours per week on billing tasks. Nurses sometimes spend up to 4 hours a day for several days on prior authorizations for a single patient. Prior authorizations can take weeks to months. Claims can be rejected, edited, denied, and resubmitted multiple times. Sometimes a lesser treatment is settled on to satisfy insurance requirements.
Sonntag and Sanchez suggest some short-term interventions such as minimizing prior authorization, and peer-to-peer documentation requirements, but suggest that results would be limited without a structural overhaul.
"The discussions we had with healthcare professionals suggest that the system is in need of significant revision that may not be possible without considering moving to another model," the authors write. "Our team is most knowledgeable about the New Mexico Health Security Plan, a program that some experts believe would offer comprehensive health care coverage to New Mexico residents and control costs."
Solution-focused contracts like the one with the Center for Social Policy are part of LHHSC's focus on addressing rising health care costs. The cost drivers project identifies the structural causes of skyrocketing health costs, hiring topic experts to evaluate and adapt promising solutions for New Mexico. It's five categories are hospital costs, complex billing and payment systems, unchecked drug prices, flawed IT systems, and the administrative burdens created by the overabundance of public and private insurance plans.
In September, it is expected that two national experts will present a preliminary report to LHHSC on ways to simplify complex insurance payment and accountability requirements.
Past reports have explored hospital budgeting innovations that support rural and independent hospitals and drug purchasing solutions that allow New Mexico to get better pharmaceutical prices.
The Health Cost Drivers framework was developed through grassroots efforts coordinated by the Health Security for New Mexicans Campaign, a coalition of 170 organizations and thousands of individuals throughout the state. Its mission is to create a homegrown Health Security system where everyone would have coverage.
Three independent New Mexico studies have been conducted during the past thirty years comparing the cost of different health coverage systems. They found a plan like Health Security would likely save hundreds of millions of dollars within five years of implementation because it addresses what we now call the Health Cost Drivers.
In addition to including systemic cost solutions, the Health Security Plan would guarantee quality health coverage, preserve freedom to choose a provider, and be overseen by a geographically representative citizens' board.
