第497集：关于医疗交易和清算中心你不知道的事可能让你付出代价，嘉宾：扎克·坎特

第四百九十七集。

Episode four ninety seven.

你对医疗交易和清算所的不了解可能会让你付出代价。

What you don't know about healthcare transactions and clearing houses could cost you.

今天我将与扎克·坎特交谈，分享一些切实可行的见解。

Here is a few actionable insights today I am speaking with Zach Kanter.

你想要了解的美国医疗创业家和高管们的对话。

American healthcare entrepreneurs and executives you want to know, talking.

不懈地追求价值。

Relentlessly seeking value.

好的。

Okay.

今天的节目是我们‘不懈追求医疗价值’系列中的一部分，这些细微之处无处不在。

This show today is part of our relentless health value, the inches are all around us series.

这里的‘细微之处’是一个隐喻，指寻找那些隐藏的医疗浪费点，作为消除所有这些微小浪费环节的第一步。

This inches talk is a metaphor for finding all those little places where there is healthcare waste as a first step in an effort to excise all these little pockets of waste.

谢恩·塞隆在第四百九十集中说了这句话，我非常喜欢，因为确实，我们周围到处都是这些细微的浪费。

Shane Ceron said this phrase during episode four ninety, and I loved it because there are inches all around us for sure.

今天我们、上周、下周以及再下周要讨论的这些细微之处，

And the thing with all these inches that we're gonna talk about today and last week and next week and the week after that.

没错。

Yeah.

这些细微之处其实都可以被消除，涉及的资金高达数百万甚至数十亿美元。

These are inches that actually you could cut them and there are millions and billions of dollars.

而且你还能提升患者护理质量。

And you actually improve patient care.

你还能改善临床团队的体验。

You improve clinical team experience.

同时，你也在消除障碍，让为患者提供正确护理变得更加容易。

Also, you're cutting out friction and making it easier to do the right thing to care for patients.

如果你的北极星是实现更好、更实惠的患者护理，那么这些都是一目了然、无需犹豫的改进。

These are no brainer kinds of stuff if your North Star is better and more affordable patient care.

但对他人而言，这却是他们的生计所在——一个人的成本，往往是另一个人的收入。

But they are also somebody else's bread and butter in a one person's cost is another person's revenue kind of way.

所以，看似理所当然的事情，实际上并不像表面上看起来那么简单，我们都深有体会。

So yeah, what makes perfect common sense might not be as easy as it might look on paper as we all know so well.

上周，我们深入探讨了利益相关方互动时产生的各种昂贵摩擦。

So last week we dug into all of the inches of expensive friction that develop when stakeholders interact.

比如临床机构、支付方和计划发起方（如自保雇主）在试图收款或付款时的情况。

Like a clinical organization and a payer and a plan sponsor, self insured employer, they try to get paid or pay.

他们试图进行合同管理。

They try to direct contract.

因为正如马克·纽曼上周所言，你会发现，数据并不是数据，数据并不是数据。

Because what will be found fast enough is that the data is not the data is not the data, as Mark Newman talked about last week.

一美元也不是一美元，一美元也不是一美元。

And a dollar is not a dollar is not a dollar.

你很快就会发现这一点。

Again, you'll find this out fast enough.

你们都知道，当你们与患者旅程中各个阶段或索赔生命周期中的各方交流时，也就是所谓的医疗交易。

All of you know when you talk to entities up and down the patient journey or across the life of a claim, otherwise known as a healthcare transaction.

要让索赔得到支付，常常是一团混乱。

It's mayhem to get a claim paid often enough.

每个利益相关方都有自己的优先事项、观点、会计方法和各种汇总方式。

Each stakeholder comes in with their own priorities and views and accounting methods and various roll ups.

我喜欢斯蒂芬妮·哈特林的说法。

I like how Stephanie Hartline put it.

她写道：医疗保健在众多环节中传递，却缺乏一条能全程保持真相的轨道。

She wrote, healthcare moves through many hands without a rail that preserves truth along the way.

责任归属断裂，真相只能事后重新组装。

Attribution breaks and truth gets reassembled later.

问题不在于能力或基础设施。

The difference isn't capability, infrastructure.

逐项计费并不等于逐项结算。

Line item billing does not equal line item settlement.

我也很喜欢克里斯·艾尔温的说法。

Or I also like how Chris Irwin put it.

他写道：当蓝图没有标准化时，你不是在扩展，而是在加剧混乱。

He wrote, when the blueprint isn't standardized, you aren't scaling, you're just compounding chaos.

确实，当缺乏一条贯穿始终的线索，没有一条将数据与数据、数据与数据，或美元与美元、美元与美元连接起来的轨道时，

And yeah, then all of a sudden, when there's no through line, there's no rail that connects all the data to the data to the data, or all the dollars to the dollars to the dollars.

突然间，任何一笔医疗交易中都有30%的成本用于试图将这一切重新理顺，正如斯蒂芬妮所说，重新组装起来。

Suddenly, 30% of any given healthcare transaction goes to trying to straighten it all back out again to reassemble it as Stephanie said.

这就像放出了100只混乱猴子，然后还得花钱把它们全部抓回来。

It's like unleashing a 100 chaos monkeys and then having to pay to recapture them all.

听听去年大卫·尚克的节目吧，他说：我们为什么不都使用同一个模板，从而避免这么多麻烦呢？

Listen to the show with David Shanker from last year about, hey, how about we all just use the same template and avoid a lot of this?

或者读读扎克·埃马纽埃尔的书，书中提到美国或许可以考虑借鉴荷兰的模式，因为荷兰有私人保险，但其行政成本降低了75%左右？

Or read Zach Emmanuel's book about how The USA should potentially consider copying The Netherlands model because they have private insurance, but they cut admin costs 75% or something like that?

哦，对了。

Oh, right.

通过标准化。

Through standardization.

杰西·亨顿前几天总结了这一点。

Jesse Hendon summarized this the other day.

他写道，一旦实现标准化，医疗机构就不需要庞大的程序员团队去应对50份不同的保险规则手册。

He wrote providers don't need armies of coders to fight 50 different insurance rule books when you have some standardization here.

我之所以说这些，是因为在录制了上周与马克·纽曼的对话后，我对这些利益相关者之间非标准化或存在摩擦的环节产生了浓厚兴趣。

I say all this to say, after recording the episode with Mark Newman from last week, I have become intently fascinated by what goes on in this non standardized or otherwise friction points between stakeholders.

在这个灰色地带、混乱的领域里，存在着大量细微的差异。

There are a lot of inches in this gray area, land of confusion.

今天的节目深入探讨了其中一个环节：处理一笔索赔究竟需要什么？

This show today digs into one of them, which is what does it take to process a claim?

从技术层面来看，提交索赔并最终获得付款（即一次医疗交易）涉及哪些流程环节？

Just technically, what are the pipes involved to submit a claim and again, get paid for it, which is a healthcare transaction.

即使管道中的所有内容都是一团混乱的非标准化系统，仅仅是技术如何在其中传输数据。

Just simply the technology moving that data around even if everything in the pipes is a non standardized hot mess.

因为仅仅修复这里的处理流程和数据通道，虽然这并不能解决整个数据不统一、美元不等值的问题。

Because just fixing up the processing and the pipes here, again, while this doesn't solve the entire data isn't a data isn't a data or dollars and a dollar isn't a dollar problem.

如果我们能削减一些处理和数据传输的成本，仅这一项每年就能节省60亿美元。

If we can just cut out some of the processing and the moving the data around costs, just this all by itself is $6,000,000,000 a year worth of inches.

此外，还有一个额外的好处：改善数据传输通道，让患者护理更快捷。

Plus as an added bonus, fix up the pipes for better data flow and now patient care can be faster.

例如，如果事先授权等流程能更快完成，而清算中心也已加入讨论。

If for example, the prior author etcetera processes transpire faster and clearinghouses have entered the chat.

但你知道，当提到清算中心时，至少在我的圈子里，这个词一出现，往往伴随着一团烟雾，因为没人清楚这些家伙整天到底在做什么。

But you know, when clearinghouses come up, at least in my world, when the clearinghouse word gets dropped, it's usually accompanied by like a puff of smoke because no one is quite sure what those guys do all day.

所以我们在对话中彼此对视一眼，然后就跳过这个话题了。

So we all sort of look at each other in the conversation and move on.

幸运的是，对我，也可能对你——如果我已经成功把你吸引进我的谜团中的话——

Lucky for me, and possibly you, if I've managed to suck you into my web of intrigue.

我遇到了来自Steady公司的一位新清算中心代表扎克·癌症，他同意来我的播客中，帮助我探索这些利益相关者之间的边界地带。

I ran into Zach Cancer from Steady, a new clearinghouse who agreed to come on the pod here and aid my exploration into this demarcation zone between stakeholders.

那我们从这里开始。

So let's start here.

什么是清算中心？

What is a clearinghouse?

嗯，清算中心其实就是一种交换机。

Well, a clearinghouse is the same thing as a switch.

当我们谈论药房数据传输时，如果你熟悉这个术语，那就很有帮助。

When we're talking about pharmacy data transfers, if you're familiar with that terminology and that's helpful.

但无论如何，在接下来与扎克·坎特的对话中，扎克会更好地解释这一点，但清算中心就像是一个枢纽，连接所有付款方和所有提供商。

But either way, in the conversation with Zach Kanter that follows, Zach will explain this better, but clearinghouses are like a hub maybe that connects all the payers with all the providers.

所以，如果你需要进行资格检查，或者想提交索赔、进行事先授权，无论你想做什么来获得付款。

So if you want an eligibility check or you wanna submit a claim or do a prior auth with a payer, whatever you're trying to do, get paid.

作为电子健康记录系统、诊所或收入周期管理公司，你无需为每个付款方单独建立自己的数据连接。

You as an EHR system or a doctor's office or an RCM, revenue cycle management company, you don't have to set up your own personal data connection with every single payer out there.

你无需逐一完成所有认证、BAAs协议，映射所有字段，并设置100个符合SOC 2标准的API。

You don't have to go through all the authentications and the BAAs and map all the fields and set up the 100 SOC two compliant APIs.

相反，你只需连接到一个清算中心，然后由它与所有其他方连接。

Instead, you can hook up to one clearinghouse, and then that clearing house connects with everybody else.

因此，大多数医疗索赔交易中间都会有一个清算中心，就像老式的电话接线员，将你的索赔、拒付、批准或资格核查等信息路由到正确的地方。

So most medical claims transactions have a clearing house in the middle, like an old timey telephone operator routing your claim or denial or approval of that claim or eligibility check or whatever to the right place.

不幸的是，根据你使用的清算中心不同，‘老式电话接线员’这个比喻相当贴切。

And unfortunately, old timey telephone operator is a pretty apt metaphor depending on which clearinghouse you're using.

无论如何，Sac Cancer告诉我，在医疗行业通过清算中心发送和接收一份电子数据的成本，大约是其他行业支付费用的1000倍。

Anyway, Sac Cancer told me that the price to just send and receive an electronic little piece of data in healthcare through a clearinghouse costs about 1,000 times more than any other industry would pay.

比如，如果你做一次资格核查，每次费用大约是10到15美分。

Like if you do an eligibility check, that's gonna cost 10 to 15¢ per.

而运输行业支付同样的费用，可以完成一千次这样的数据传输。

The trucking industry pays that much for a thousand such data transfers.

如果有人要求他们为十次数据传输支付一美元，他们会抗议的。

They would riot if someone asked them to spend a dollar for 10 data transfers.

在他们看来，这简直荒谬至极。

That'd be ridiculous in their eyes.

但在医疗行业，这些零钱加起来每年又达到了60亿美元。

But in healthcare, all these dimes add up to again, $6,000,000,000 a year.

这些小费用也导致了付款和患者护理的延迟。

Them's some inches there, which also equal delays in payment and patient care.

你现在可能会想，哦，也许这是因为医疗行业比卡车行业或其他行业复杂得多，所以才这么贵。

Now you might be thinking, oh, well, maybe it costs this much because healthcare is so much more complicated than trucking or whatever.

但事实恰恰相反，这要归因于HIPAA。

Well, turns out the opposite is true because of HIPAA.

讽刺的是，医疗行业实际上更加标准化。

Ironically enough, healthcare is in fact much more standardized.

我们之前谈过标准化的问题。

We're talking about standardization before.

但由于HIPAA的行政简化规则，医疗行业实际上比许多其他行业更加标准化，这些规则强制要求统一的交易语言。

But healthcare is actually much more standardized than many other industries due to HIPAA's administrative simplification rules, which mandate a universal language for transactions.

我现在所谈论的这些‘管道’。

The pipes I'm talking about now.

所以实际上，尽管我刚才谈到了混乱猴子，但与其它行业相比，这里的底层架构实际上要有序得多，比如卡车行业，或者亚马逊或沃尔玛与数百万供应商打交道时所面临的状况。

So actually, for as much as I was just about chaos monkeys, compared to other industries, the baseline construct here is actually much more orderly than, for example, the trucking industry or whatever like Amazon or Walmart has to deal with with their millions of vendors.

现在，这里有一个非常重要的观点，尤其对于自保雇主来说。

Now, and here's a really big point, especially for self insured employers.

你知道许多更具程序化、更新类型的清算所的主要客户是谁吗？

You know who the main customer is for a lot of the more programmatic, the newer kinds of clearinghouses?

我来告诉你，是那些为医疗机构提供收入周期管理（RCM）服务的新型数字实体。

I'll tell you, newer digital entities who do RCM, revenue cycle management, for provider organizations.

如果你是一家努力应对付款方拒付并加快患者护理的诊所，这当然是件好事。

And that can be great if you're a practice just trying to keep up with payer denials and expedite patient care.

但听好了，所有计划发起人、自保雇主，还有可能存在的工会，当越来越多的RCM服务提供商与程序化清算所合作时，而你们却没有与无利益冲突的第三方预付完整性供应商合作，这些供应商与RCM供应商一样深度接入数据流和清算所，那么正如我上周所说，你们正越来越像是拿着一把生锈的刀去参加枪战。

But look, all you plan sponsors and self insured employers and maybe unions out there, the more RCM purveyors start working with programmatic clearinghouses, the more you not doing programmatic prepayment integrity programs with unconflicted third party prepayment integrity vendors who are as hooked into the data streams and the clearinghouses as the RCM vendors are, the more as I said last week, increasingly, you're bringing a ever more rusty knife to a gunfight.

所以这确实值得考虑。

So that is certainly something to consider.

下周将有一整集内容讨论这个问题，嘉宾是Claims Insight的Mark Noel。

There's a whole episode next week about this with Mark Noel from Claims Insight.

或者如果你等不及了，回去听听金伯利·卡尔森的那期节目，了解一下大致内容，或者几年前唐·科尼利斯的那期。

Or if you just can't wait, go back and listen to the show with Kimberly Carlson just for the gist of it or the one with Don Cornelis from a few years ago.

他们讨论的是付款后完整性计划，但很多相同的规则仍然适用。

They're talking post payment integrity programs, but a lot of the same rules apply.

我的名字是斯泰西·里希特。

My name is Stacy Richter.

今天的节目一如既往由Aventria健康集团赞助。

The show today is sponsored by Aventria Health Group as usual.

但我确实想说明，我们非常感谢Steady提供的财务支持，Steady是唯一可编程的医疗清算机构。

But I do want to say that we got some very appreciated financial support from Steady, the only programmable healthcare clearinghouse.

接下来是我与Zach Kanter的对话，他正是Steady的首席执行官兼创始人，我们将探讨围绕我们的所有细节，特别是医疗数据管道中的情况。

And here's my conversation about all of the inches that are all around us, specifically in the healthcare data pipes with Zach Kanter, who is the CEO and founder over at Steady.

Zach Kanter，欢迎来到Relentless Health Bayou。

Zach Kanter, welcome to Relentless Health Bayou.

谢谢你的邀请。

Thank you for having me.

很高兴能来这里。

Excited to be here.

那我们从结尾开始吧。

So let's let's begin at the end here.

当我们思考医疗浪费时，我今天非常想探讨的是：我们可能在为一些完全不知道自己在支付的东西买单，尤其是那些最终耗资数十亿美元、而我们却不太 aware 的项目。

As we're thinking about health care waste, what I'm very intrigued to talk about today is what are things that we might be paying for that we have no idea that we're paying for, especially things that ultimately wind up costing billions and billions of dollars that we might not be so aware of.

相对而言，医疗交易成本高吗？

Relatively speaking, are health care transaction costs high?

当我们关注用于处理交易（如索赔、资格核查和索赔状态）的巨额资金时。

When we look at the size of of the dollars that are being expended on just the processing of the transactions like claims and eligibility checks and claim status.

你谈论的金额大约在50亿到70亿美元之间。

You're talking in the neighborhood of, call it 5 to $7,000,000,000.

从交易成本的角度来看，与其他行业相比，这个数字高出数百甚至数千倍，这意味着，就论点而言，这50亿到70亿美元应该减少90%。

And how that compares from a transaction cost standpoint to other industries, it's hundreds or thousands of times more than you're seeing in in other industries, which means that for argument's sake, that 5 to $7,000,000,000 should go down by 90%.

50亿到70亿美元。

5 to $7,000,000,000.

与其它行业相比，这显然非常过分。

It's obviously egregious compared to other industries.

如果我只考虑每笔交易的成本，不管我们怎么计算，成本差异有多大？

If I'm thinking about just maybe the cost per transaction, however we wanna do this, what's the difference in cost?

当你比较发送索赔的费用时，作为高容量提交者，单次往返费用在10到15美分之间；而如果你要大规模发送商业邮件，即使规模很小，发送一千封邮件也只需大约15美分。

When you compare the cost of sending a claim which is in the 10 to 15¢ range round trip as a high volume submitter, if you're paying for it to send business emails at scale, you know, even a very small scale, you're paying something like 15¢ for a thousand emails.

因此，发送一封邮件的成本只是发送一份索赔费用的千分之一。

So you're paying one one thousandth of the price to send an email that you are to send a claim.

从数据角度来看，这个数字根本对不上。

And when you look at that from a data standpoint, the math kind of just doesn't add up.

当你看到人们被收取1%、2%、甚至2.5%的ACH费用时，而这些服务在其他行业几乎是免费的，或者只收几分钱。

When you look at people being charged, you know, one, two, two and a half percent for for ACHs that in other industries cost nothing or pennies.

我听到你说的是，在其他所有行业，无论你是发短信来回沟通，还是亚马逊试图与任何对象进行交互，你为传输数据进行商业往来，每千条数据只需支付10到15美分。

What I'm hearing you say is that elsewhere, in every other industry, whether you are a text message going back and forth, whether you're Amazon trying to talk to whatever you're trying to do, you're gonna pay $10.15 cents for a thousand, whatever data you're transmitting back and forth in order to do commerce.

但在这种情况下，你每笔交易却要支付10到15美分。

In this particular case, you're paying that $10.15 cents per.

这听起来太荒谬了。

That sounds nuts.

是的。

Yeah.

完全不合理。

It's completely out of whack.

医疗行业有什么特殊之处导致了这种情况吗？

Is there something special with healthcare or something like that that would account for this?

这是个很好的问题，我认为答案是医疗行业确实有很多特殊之处，但实际情况应该恰恰相反。

Well, it's a great question because I I think the answer to that is there is a lot that's special about healthcare, but it actually should work in the opposite direction.

医疗行业的特殊性本应使其成本更低。

The things that are special about healthcare should make it cheaper.

HIPAA，大多数人知道HIPAA是一个合规和隐私框架。

HIPAA, most people know of HIPAA as a compliance and privacy framework.

它还除此之外确立了所谓的行政简化规则，强制要求医疗行业各方使用一套标准化的交易格式，即X12，但这并不是特别重要。

It also did among other things establish something called the administrative simplification rules, which mandated that all the parties in healthcare use a set of standardized transactions, which are known as X12, but that's not super important.

标准化了资格检查、索赔、索赔状态、电子付款通知（即关于返回付款的信息）。

Standardized the eligibility check, the claim, claim status, electronic remittance advice, which is the information about the payment that came back.

并且规定所有人都必须完全遵守该规范。

And it said that everybody has to follow the specification exactly.

因此，是的，该规范非常冗长，比如一份索赔的规范可能有六百五十页的PDF，所以实现起来很复杂。

And so yes, the specification is lengthy, know, the specification for a claim might be six fifty pages as a PDF, so it's complicated to build out.

但这意味着这些交易在功能上看起来是一样的。

But what that means is that the transactions functionally look the same.

是的，存在支付方特定的差异，但当你比较这两个支付方的交易与亚马逊或沃尔玛的交易时，你需要处理的数据集要窄得多。

And yes, there's payer specific differences, but when you talk about the difference between one of these two payers transactions versus Amazon versus Walmart, it is a much, much narrower set of data that you have to work with.

因此，在此范围内，还有许多其他很棒的方面， podcast 听众可能会觉得称这些为‘很棒的东西’很奇怪。

So within that, there's also all these wonderful things, which people in the podcast might think this is strange to call these things wonderful things.

比如 ICD-10 编码、CPT 和 CDT 编码、HCPCS 编码，这些虽然可能是繁琐的维护清单，但它们确实是清单。

You know, like ICD-ten codes and CPT and CDT codes and HCPCS codes, which are, yes, they're maybe cumbersome lists to maintain, but they are lists.

它们是每个人都必须遵循的规范。

They are things that everybody has to conform to.

我们曾经多么渴望在零售和物流领域也能有这样的标准：看，对于这个特定字段，所有人都必须使用相同的规范。

And we we would have killed for things like that in retail and logistics that say, look, here's a for this particular field, here's what everybody has to use.

所以你所说的非常有趣，我一开始问医疗行业是否特殊，是以为你会说：哇，医疗行业更复杂。

So it's so interesting what you're saying that, you know, I asked if healthcare was special immediately thinking that you were gonna say, wow, healthcare is more complicated.

因此，也许医疗交易成本高出一千倍是有道理的。

And therefore, maybe there's a rationale for why healthcare transactions should cost a thousand times more.

但实际情况恰恰相反。

And actually here we have the opposite.

在其他行业，情况简直就是无法无天的西部荒野。

That of in other industries, it's very much the Wild West.

它们根本没有这些标准化规范。

They do not have these standardizations.

一旦有了这些交易标准，交易成本实际上应该更低，因为每次发送交易时，你都不必把数据发到一片无法无天的荒野中，去碰运气，希望对方使用的是和你一样的标准。

Once you get the stuff transactions themselves should actually be less expensive because every single time you send a transaction, you're not sending it into the Wild West hoping that somebody on the other side is using the same standard as you.

我们已经建立了这一切，你们使用的是相同的电子数据传输语言，你们拥有像代码这样的标准化清单。

Like, we have all this set up already, you're using the same electronic data transmission language, you've got lists of things like a code as a code.

所以，没错，这出乎意料。

So, yeah, that was unexpected.

而且我认为，人们常常混淆简单与复杂、复杂与标准化的概念。

And look, I think people often get the concept of simple versus complicated or complex versus standardized confused.

是的，医疗保健领域确实非常复杂。

Yes, things are indeed very complicated in healthcare.

医疗保健领域也非常复杂。

They're very complex in healthcare.

它涉及许多方面。

There's many dimensions to it.

有很多事情必须做对，也有很多事情不能出错。

There's a lot of things you have to get right, a lot of things you can't get wrong.

有很多数据字段需要来回传递，但这些都已经标准化了。

There's a lot of, you know, data fields that need to be passed back and forth, but it is standardized.

软件行业的人喜欢标准化，因为当你着手解决问题时，虽然处理一个索赔可能需要应对七百四十二个不同的字段，但至少我们知道里面会有什么。

People in software love standardization because it means that when you're sitting down to solve a problem, yes, there might be seven forty two different fields that you need to deal with for a claim, but at least we know what we're going to expect in there.

这被称为有界集，或者说有界问题，而不是无界问题。

It's, you know, it's called a bounded set, as a bounded problem as opposed to an unbounded problem.

我听到的是，每笔索赔交易的10到15美分，加起来每年高达数十亿美元。

What I'm hearing relative to this 10 to 15¢ a claim transactions that adds up to billions of dollars a year.

我们有标准化的编码。

We have standardized codes.

我们这里有一个标准化的体系，我知道很多人对HIPAA有很多看法，但我想这算是一个优势。

We've got a standardized situation here that, know, I can say a lot about HIPAA, but I guess this is a plus.

医疗保健在某些方面是特殊的。

Healthcare is a special in good way.

然而，奇怪的是，也许这是一种预示，发送一笔交易的成本却高出一千倍。

And yet, oddly, and maybe this is foreshadowing, oddly, it's a thousand times more to send a transaction.

我听说的另一点关于医疗保健的是，如果我们思考一下这个问题的各个维度，那就是延迟和潜在的低效，我想这或许正是人们能够以每笔索赔10到15美分的成本处理本应低一千倍成本事务的原因。

Another thing that I have heard about healthcare, just if we're thinking through sort of the dimensions of this, another one is delays and just the inefficiency that could potentially be involved, which I guess, you know, maybe that's part and parcel to how people are managing to spend 10 to 15¢ a claim for something that should be a thousand times less if you or anybody else in the world.

其他行业处理这种来回交易需要多长时间，相比医疗保健呢？

How long do other industries take to process that bing bing back and forth versus healthcare?

我认为，医疗保健在某些方面领先，在其他方面则落后。

Well, I think that this is where healthcare is ahead in some ways and behind in other ways.

所以，当你从正面来看时，这些交易在验证方面有更高的要求，除了少数例外，如果你发送了一个无效的交易，比如一个没有有效ICD-10代码的索赔，你会收到拒付通知。

So when you look at the positive side of it, is that much more is expected from a validation standpoint in these transactions and with some exceptions, if you send an invalid transaction, so you send a claim that doesn't have a valid ICD 10 code, you're gonna get a rejection notice from someone.

希望这能在链条的早期就发生，但在某些情况下，它可能会一直传到付款方那里。

Hopefully that's early on in the chain, but it might make it all the way to the payer in some cases.

而付款方，你知道，也许是因为他们的系统非常老旧，或者是因为付款方没有很强的动力快速处理拒付，但你最终还是会收到拒付通知。

And the payer, you know, maybe because the the payer systems are very old or maybe because the payer doesn't have a really big incentive to turn around a rejection very quickly, but you are gonna get a rejection notice that comes back.

所以你会收到某种反馈，希望它能提供一个相当清晰的错误信息，告诉你你发送的ICD-10代码无效。

So you're going to get something and hopefully it's going to have a pretty good error message that's going to tell you that ICD-ten code that you sent was non valid.

在其他行业，情况并非如此。

In other industries, that's not the case.

所以在物流和零售行业，如果你发送了一个无效的追踪号，你可能根本听不到任何回音，这笔交易可能永远得不到付款。

So if you send a tracking number that's invalid in the world of logistics and retail, you might just not hear anything at all and that transaction might never get paid.

你可能不得不打电话，然后去追踪事情的进展。

And you might have to, you know, then make a phone call and chase things down.

我敢肯定人们会想，我不得不给付款方打过很多电话，但从大致的覆盖范围来看，医疗保健中的这些自动拒付通知所涵盖的内容比其他行业多得多。

And I'm sure people are thinking, I've had to make plenty of phone calls to payers, but from a a rough coverage standpoint, there's a lot more covered in these automated rejection notices in health care than there than there is elsewhere.

现在我说，这方面的缺点是，这些交易的速度远未达到应有的水平，而且也没有在流程中尽早发生。

Now I'd say like the downside of this, the transactions are nowhere near as fast as they could be and they're not happening as early as they can in the process.

所以人们会谈到其中一些交易被商品化了。

So people talk about some of these transactions being commoditized.

索赔被商品化了。

A claim is commoditized.

资格核查被商品化了。

An eligibility check is commoditized.

对我来说，商品化意味着价格低廉，与其他行业相当。

To me, commodity means it's dirt cheap, you know, in line with other industries.

它是完全可互换的，而我认为我们已经讨论过，它并不便宜这一点显而易见。

It's totally interchangeable and I think like we've already talked about it, the fact that it's not cheap is pretty obvious.

我们谈过它完全是可互换的。

We talked about it being totally interchangeable.

如果它真的是完全可互换的，当Change Healthcare系统崩溃时，我认为这根本不会成为事件。

If it were totally interchangeable when Change Healthcare went down, I think it would have been a non event.

但关键是，你不应该等到交易到达像付款方或第三方管理员这样的最终接收方时，才发现你发送的代码无效，或者触发了NCCI编辑规则之类的问题——这些基本的索赔验证规则，你不应该等这么久。

But the bottom line is that you shouldn't have to wait all the way for a transaction to get to one of these destination parties like a payer or a third party administrator to find out that a code that you send is not valid or that there's an NCCI edit that was triggered something like that, know, one of these basic claims validation rules, you should not have to wait that long.

所以，如果我考虑医疗行业特有的另一个主要问题，一般来说，在其他行业，你发送一个交易后，可能什么反应都没有，也可能立刻得到回应。

So if I'm thinking about a second kind of top line issue that we have in healthcare that we may not have in other industries, generally speaking in other industries, you send a transaction and maybe hear nothing or maybe you hear instantly.

但在医疗行业，情况并非如此。

That is not what we've got going on in healthcare.

有时，一个索赔或交易需要四到五天才能得到处理。

Sometimes it takes four to five days for a claim or transaction to get dealt with.

你能具体谈谈这四到五天的延迟是从哪里来的吗？

Can you very specifically talk about where that four to five days comes from?

如果我们把它与其他行业相比，情况如何？

And if we're comparing it to other industries, how does it compare?

你得稍微回溯一下，想想我们是怎么走到这一步的。

You have to kind of rewind the clock a little bit and think about how do we get here.

以前，理赔申请是通过纸质邮件发送的。

It used to be the claims are sent via paper mail.

因此，HIPAA行政简化的主要努力虽然确实有早期电子交易的雏形，他们希望标准化这些交易，但真正目标是停止邮寄纸质理赔申请和纸质支票。

And so the big effort of HIPAA administrative simplification, sure it was like there was some, you know, early beginnings of electronic transactions that they wanted to standardize, but they're really trying to get paper claims to stop being mailed and for paper checks to stop being mailed.

所以，当从纸质流程转向电子流程时，即使能在几天内收到反馈也已经很不错了。

And so when you move from a paper process to an electronic process, even hearing back in a couple of days is is great.

在软件世界中，这被称为批处理或异步交易：将大量文件放入系统，由系统批量提取这些文件。

And these are in the software world is what's known as as batch or asynchronous transactions to drop a bunch of files in there, to picks up these files.

你所合作的清算中心可能每三十分钟检查一次新文件，也可能每三小时检查一次新文件。

A clearinghouse that you work with, maybe they look at for new files every thirty minutes, or maybe they look for new files every three hours.

但它们几乎不可能每两秒就检查一次新文件。

But like they're probably not looking for new files every two seconds.

尽管如今完全有能力实现每两秒检查一次，但当时的系统并未设计成这样。

Despite the fact that that's entirely possible to do today, the systems just weren't built to to do that at the time.

现在，清算中心在提取文件后，可能会将它们放入队列，然后每三十分钟、一小时、三小时、六小时或十二小时发送一次。

Now, maybe the clearinghouses transmit those once they've picked up the files, maybe they put them into a queue that then gets sent out every thirty minutes or one hour or three hours or six hours or twelve hours.

也许他们每天发送一次。

Maybe they send them once a day.

也许这样做是为了省钱，也许是因为此时他们难以改变计算系统，你知道，他们可能还在使用本地数据中心而不是云平台，所以系统就是这么设置的。

Maybe they do that to save money, maybe they do that because the compute is difficult for them to change at this point, you know, that maybe they're running on an on prem data center instead of in the cloud and they that's how they have things set up.

在某些情况下，付款方可能会说，我们不接受每天超过一次的索赔。

In some cases, maybe the payers say we don't want claims more than once a day.

所以你不能一收到索赔就发送给我们，必须将它们批量处理。

So you can't the claims to us as you receive them, have to batch them up.

现在，交易从清算中心发送到付款方，而付款方也需要执行类似的监听任务。

Now the transaction goes from the clearinghouse to the payer, and now the payer has the same sort of listening job.

他们会实时监听索赔吗？

Are they gonna listen for the claims in real time?

几乎可以肯定不会。

Almost certainly not.

他们是每三十分钟、三小时、十二小时监听一次，还是每24小时监听一次？

Are they gonna listen on thirty minutes, three hours, twelve hours, once every twenty four hours?

当交易返回时，过程也是以同样的方式在反向进行。

And then when the transactions come back, it happens, the same way on the way back.

当然，在交易经过付款方的核销流程并流经付款方的各种系统时，这些环节中的每一个都可能被设置为批处理任务。

And of course, as it goes through the payer's adjudication process and it's going through the various systems that the payer has, you know, each one of these things can be set up on a batch job.

所以当你思考这个问题时，想象一下你正在穿越一系列火车站，从海岸到海岸旅行，而火车每天只发一趟。

So when you kind of think about this, imagine you're going through a series of train stations, you're traveling coast to coast and the train leaves once a day.

如果你把这些环节完美地对齐，你的旅程可能会相当快。

If you line these things up perfectly, you might have a pretty quick trip.

如果你没有把这些环节完美地对齐，你可能会面临很长的延误。

If you don't line these things up perfectly, you might be facing a very long delay.

你到达时刚好错过火车一分钟，现在你得等将近二十四小时才能等到下一班列车。

You get there one minute after the train has left, and now you're waiting almost twenty four hours for the next train stop.

我们接下来要探讨的一个问题是：我们是如何走到这一步的？为什么？以及要解决它需要什么？

One of the questions that we're gonna circle up on is how did we get here and why and what's it gonna take to fix it?

我认为我确实触及到了一个观点，那就是我们这里存在的是遗留流程。

And and I think I am definitely cutting onto the notion that we've got legacy processes here.

我们有遗留系统。

We've got legacy systems.

关于这一点，你必须考虑到，一天、十二小时、两天，每一个这样的日子都是医疗机构等待收款的日子。

One piece on that you have to think about like, oh, a day, a twelve hours, two days, this and every one of those days is a day that the provider needs to wait to get paid.

所以，这又是另一笔应收款的延迟。

So that that is another day of receivables.

这又是他们不得不垫付资金以等待收款的另一天。

That is another day that they're having to float that cash in order to get paid.

这是一个巨大的问题。

And this is this is a huge problem.

这就像

This is like the

那么，从

Well, and then from

患者

a patient

从患者的角度来看，这是又一天，患者不知道他们的预先授权是否获批，或者其他情况。

standpoint, this is another day where a patient doesn't know whether their pre auth is approved or whatever.

所以这是癌症治疗的又一个延误。

So this is another delay in the cancer care.

这是关于是否应该做MRI的又一个延误。

This is another delay in should we actually do the MRI?

这是另一个延误，对吧？

This is another delay, right?

正如你所说，这是一个非常好的补充，这不仅仅是某种技术性地搬运货物。

Like, so these are to your exact point, that was an excellent add that this is not just some kind of technological moving freight around.

这实际上是

This this is

这是患者可能已经发生变化的又一天，患者可能已经忘记了这个程序的具体内容，从而降低了收取患者剩余费用的可能性。

It's it's another day that the patient might have moved now, the patient might have forgotten what the procedure was was about and reduces the chances of collecting the remaining patient for financial responsibility.

我认为你可以从这样的立场出发：这些事情应该是实时的。

I think like you can start from the position of saying these things should be real time.

这些事情应该极其便宜，而且应该是实时的。

These things should be ultra cheap and they should be real time.

我认为你应该从这个前提出发倒推。

And I think that you should work backwards from that premise.

现在我们可以讨论为什么实际情况并非如此。

And now we can talk about why that isn't the case.

你知道吗，付款方会支付这个索赔吗？因为这必须经过某种临床审核？

Know, is is the payer going to pay this claim because that has to go through some sort of a clinical review?

当然。

Sure.

这超出了我们当前讨论的范围。

That is outside of the scope of this.

但对于基本的验证规则——有数以万计的技术性规则——这些事情应该是即时的。

But for the basic validation rules of which there are tens of thousands technical rules, these things should be instant.

无论我们做什么，如果你只是因为技术低效而随意增加天数，这看起来应该是每个人都会关注并解决的问题。

No matter what we're doing, if you're just adding random days for no reason other than technological inefficiency, it would seem to be something that everyone would have eyes on fixing.

这实际上会改善患者护理。

It it actually will improve patient care.

我们并不是在讨论消除行政影响对患者护理的影响。

We're we're not talking about removing administrative impacts patient care.

这并不是我们在这里讨论的内容。

This is not what we're talking about here.

我们讨论的是提高效率，以改善患者护理并降低成本。

We're talking about improving efficiency to improve patient care and reduce costs.

好吧，让我们理清一下我们在这场对话中的位置。

Okay, let's level set where we are in this conversation.

到目前为止，我们已经讨论了两个问题。

We've talked about two issues so far.

这些在医疗机构和付款方之间、通过清算所传递的索赔交易，第一个问题是成本高昂。

These claims transactions back and forth between providers and payers that go through clearinghouses, they are number one, expensive.

比其他行业贵一千倍，每年累计达到50亿到70亿美元，而成本本应比其他行业低90%左右，因为那些行业的交易实际上更复杂、标准化程度更低。

A thousand times more expensive than other industries, adding up to 5 to $7,000,000,000 a year when the cost should be something like 90% less as compared to other industries where transactions are actually harder and less standardized.

然后我们谈到了本次对话中的第二个问题。

And then we have number two where we are in this conversation.

这些交易耗时更长。

These transactions take longer.

如果不需要临床审核或人工干预，它们应该是瞬时完成的。

If there's no clinical reviews or manual labor required, they should be instantaneous.

但它们却要花上好几天。

And yet they take days.

你看，这看似是个技术问题，但实际上并不是技术问题。

Now look, this is a technology problem, except it's not a technology problem.

这是一个激励机制的问题。

It's an incentives problem.

没有人会去修复这项技术。

No one is going to fix technology.

他们有动力维持这种糟糕的现状。

They have an incentive to keep crappy.

听听普雷斯顿·亚历山大关于支付方在资金滞留期间赚取多少利润的节目。

Listen to the show with Preston Alexander about how much payers make in the float.

还有最近一期与埃里克·布里克医生的访谈，他也说了同样的话。

And also the most recent show with doctor Eric Bricker, he says the same thing.

这全都是关于资金的时间价值，宝贝。

It's all about the time value of money, baby.

你把数十亿、数万亿美元多保留几天，平均多留41天。

You keep billions, trillions of dollars for a few extra days or forty one days on average.

视情况而定，你一年能额外获得10%到20%的利润。

As the case may be, you make an extra 10 to 20% in profit across a year.

正如人们所说，你因此获得了不少底气。

You get lots of swagger as they say.

想想看，谁拥有一个或多个大型清算所的所有权，这种底气意味着什么。

And consider the swagger in the context of who owns one or more of the big clearing houses.

哦，对了。

Oh, right.

一个付款方。

A payer.

此外，还有一些清算机构拥有少数几个大型付款方客户，这些客户在中间将这些交易的成本作为其医疗损失率（MLR）的一部分转嫁出去。

And also there are other clearing houses who have a few very large payer customers who are in the middle passing on the costs of these transactions as part of their MLR, their medical loss ratio.

这些被视为医疗支出，从而推高了作为其利润计算基础的医疗成本。

These are considered medical expenses, thereby driving up the costs that are the basis for how much profit they can make.

因为别忘了，如果一个付款方的利润只能在医疗趋势基础上达到约15%，那么医疗支出越高，他们能赚的利润就越多。

Because don't forget, if a payer can only make 15 ish percent profit over medical trend, then the higher the medical expenses, the more profit they can make.

对吧？

Right?

你们很多人已经知道这一点了。

Many of you know this already.

但没错，技术是解决方案，但在某种程度上，它也不是问题本身。

But, yeah, the technology is the fix, but it is also, to some extent, not the problem.

或者说，知道如何修复技术并不是问题所在。

Or at least knowing how to fix the technology is not the problem.

然后，考虑到我们刚刚讨论的这些交易成本高昂且耗时较长，我也理解第三个问题是它们不透明，这里缺乏一定的透明度。

And then, you know, just given all the exactly what we we have just been talking about with these transactions that are costly and take a while, I am also understanding that a third issue is they're opaque, and there's some lack of transparency here.

你知道，提出一个问题：提供方对已处理理赔的可见度到底有多少？

You know, asking a question of, hey, how much visibility does somebody on the provider side happen to a claim that gets processed?

对于同时使用交换中心和大多数电子健康记录系统（EHR）的人来说，有很多挫败感，因为EHR通常要求你注册外部交换中心。

A lot of frustration with people who are using both a clearinghouse and the majority of EHRs require that you sign up with an external clearinghouse.

而且这些系统集成得不好。

And these systems are not well integrated.

就像是在你的EHR内部生成理赔申请，然后当出现问题时，它被丢给交换中心处理。

Like it's a claim gets generated inside your EHR and then it gets dropped into the clearinghouse when something goes wrong.

这就像是一种分裂脑问题，问题出在哪里以及为什么会发生这些情况都有些模糊不清。

It's just this kind of split brain problem where it's a bit ambiguous as to where the problems are occurring and why exactly these things are happening.

在其他情况下，有人可能使用的系统完全隐藏了交换中心，他们甚至可能不知道交换中心是什么。

In other cases, someone might be using a system where the clearinghouse is totally obscured they may not even know what a clearinghouse is.

如果你使用的是那种把所有功能都打包在内部的系统，这可能是你第一次听说交换中心。

This might be the first time you're hearing about a clearinghouse if you are using one of these systems that has all of this packaged under the hood.

我认为，再次回到许多清算所系统乃至所有现有清算所系统的遗留性质，它们无法提供现代软件应有的深度系统集成水平。

And I think that, again, to come back to the legacy nature of a lot of the clearinghouse systems or all of the clearinghouse systems that are out there, they don't afford the same level of deep systems integration that you would expect out of a modern piece of software.

从患者、医生或计划赞助者的角度来看，这会非常令人沮丧，因为你可能会想：X、Y、Z的状态到底怎么样？

And from a patient perspective or a physician perspective, that would be really frustrating or plan even a plan sponsor perspective because you're like, well, what's the status of x, y, and z?

而问题可能出现在沿途的任何一个环节。

And it could be at any one of those train stops along the way.

你无法查询系统来发现它卡在了哪里。

Like, you can't query the system and discover that it's held up here.

我们已经确定这些交易成本高昂。

We've determined that these transactions are expensive.

它们相对缓慢，或者可能变得缓慢。

They're relatively slow or could be.

尽管这些交易本应标准化，但仍有大量数据在多个遗留系统之间传输。

You've got bits and bytes that are flying around within multiple legacy systems despite the fact that they should be standardized.

所以你本应能说：哦，它们是标准化的。

So you should be able to say, oh, they're standardized.

所以它应该是一种大宗商品。

So it should be a commodity.

但事实并非如此。

That is in fact not true.

因此，本应以光速传输的东西，可能需要四天才能往返完成。

Therefore, could take four days for a, you know, something that should travel at the speed of light to make it there and back.

而且由于缺乏透明度，系统中存在大量不透明性，因为我的信息包到底在哪里？

And then there's a lot of opacity and lack of transparency within the system simply because again, where is my little packet of information?

它是什么时候被批量处理的？

When did it get batched up?

它是什么时候被发送出去的？

When did it get sent out?

它现在在哪里？

Where is it?

谁拥有它？

Who has it?

我们到了吗？

Are we there yet?

这整件事给我的主要体会就是。

It is kind of my takeaway from this whole thing.

所以如果我们讨论这里应该发生什么，我是一名医生，我已经提交了一项服务。

So if we're talking about what should be happening here, I am a doctor, I have submitted a service.

我想知道我的病人该付多少钱，以及我将得到多少报酬。

I wanna know how much my patient should pay versus how much I'm gonna get paid.

于是我进入我的电子健康记录系统和诊所管理系统，输入代码和病人姓名。

So I go in my EHR, my practice management system, and I type in the code and my patient name.

那么现在应该发生什么？

And what should happen right now?

就像追踪这个数据，一路跟着它经历叮叮叮、叮叮叮、叮叮叮的过程。

Like follow that piece of data like through the cha ching, cha ching, cha ching.

这应该怎样运作？

How should this work?

我认为，理想的情况是，提交索赔的可以是医生本人，也可以是专业的收入周期管理人员。

I would say look, the way it should work, it could be a doctor who's submitting their own claims or it could be professional revenue cycle management person.

所有事情都应该是实时的：当你在EHR、清算中心或其他系统中点击‘验证’按钮时，所有无需保险公司参与即可验证的信息，都应该立即得到验证。

It should be that everything in real time, the moment that you you click a button that says validate in your in your EHR, clearinghouse, whatever it is, you should get 100% of the things that can be validated without the payers input should be validated right then and there.

这看起来相当直接。

And that seems fairly straightforward.

当然，有数以万计的规则适用，但绝不应该出现提交索赔后，三天后才发现患者在该日期没有有效保险的情况。

This is you have, yes, there's tens of thousands of rules that apply, but it should never be that you submit a claim and then you find out three days later, hey, that the patient didn't have active insurance on that date.

你通过资格核查就可以知道这一点。

You can you know that from the eligibility check.

你不应该在十二小时后或三分钟后才发现ICD-10代码无效。

You should never find out twelve hours later or three minutes later that the ICD 10 code was not valid.

你应该实时就知道这一点。

You should be you should know that in real time.

你绝不应该在瞬间之后才得知问题。

You should never find out more than instantly.

你永远不应该在提交后才发现索赔总额对不上。

You should never find out that the claim totals don't bounce.

如果你有两条金额为10美元的记录，但总额却是30美元，这种验证应该非常简单。

That if you have two lines that are $10 and the total is $30 that validation should be very cheap.

当索赔提交后，当然，你无法改变保险公司的 adjudication 系统。

And then when the claim is submitted, the claim should be, you know, of course you can't change the payers adjudication system.

如果 adjudication 需要几天时间，那是你无法控制的。

And if that's gonna take days to adjudicate, that's out of the control.

但所有我们所说的、可以通过一组规则确定性评估的内容，都应当立即进行评估。

But but everything that is what we say deterministic that can be evaluated through a set of rules should be evaluated instantly.

如果我们考虑那些可以通过规则集验证的确定性事项，比如我漏填了必填字段，我应该立即收到提示，告诉我遗漏了内容。

And if we're thinking about things that are deterministic that should be validated by a set of rules, if I forgot to fill out a field that is not optional, I should immediately get a ping back that said you forgot something.

正如你所说，如果患者实际上没有有效保险，这一点应该迅速反馈回来。

If as you said, if if the patient actually doesn't have enforced coverage, then that should come back super quick.

如果我输入的ICD-10代码打错了，也应该快速反馈。

If I mistyped in ICD 10 code, that should come back quick.

还有没有其他经常发生、却要花好几天才能发现错误的例子？这些都应该是业务规则。

Are there any other big examples of just things that happen all the time that it takes multiple days for somebody to figure out are wrong that shouldn't this is a business rule.

是的。

Yeah.

我们这里其实是在讨论一些显而易见的例子，因为它们更容易解释。

Look, we're kind of going through the obvious ones here because they're easy to easier to explain.

还有很多问题是可以解决的。

There's a lot of things that can be solved.

但你看，某些ICD-10代码根本不该用于特定性别或年龄段。

But you look at things like certain ICD-ten codes don't belong to certain genders or to certain ages.

或者看看那些医学上不太可能的情况。

Or you look at medically unlikely scenarios.

如果你是个足病医生，大概就不该给出心脏病的诊断。

If you're, you know, podiatrist, you probably shouldn't be giving a cardiology diagnosis.

还有很多情况，虽然不是完全确定，但也非常接近确定。

There's like a bunch of things that if not deterministic are pretty close to deterministic.

但我想重点是，这些大问题并不是只有三四个。

But I think the point is that it's not like there's three or four of these big rocks.

而是有成千上万个。

There's thousands of them.

成千上万个，而且它们都应该立即被返回。

Thousands and thousands of them, and they should all be returned instantly.

如果这些业务规则不存在，那么从提供商、患者，甚至健康计划的角度来看，错误就会发生。

Like if there aren't these business roles, then from a provider standpoint, a patient standpoint, even from a health plan perspective, like this is when mistakes get made.

这时，分钟会变成小时，小时会变成天，成本就开始上升。

This is when, again, minutes turn into hours turn into days and cost starts to increase.

你可以想象一下，这些延迟所造成的效率低下螺旋。

You can just think about the spiral of inefficiency that's created by some of these delays.

如果你在患者坐着的时候就知道了，那么现在要过好多天才能发生的事情，当时就能处理。

If you knew about it while the patient was sitting there, then things could happen that now can happen multiple days later.

完全正确。

Exactly right.