Gabe switches doctors: A health care story | Oscar Rx | hioscar Blog | Oscar
Gabe switches doctors: A health care story
A spotlight on a few key challenges in health care – and what Oscar’s doing to overcome them.
Behind the ScenesOur Culture
8 min read
Ashley Taylor Anderson
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Gabe Drapos, Oscar’s Chief of Staff, considers himself relatively savvy about healthcare. But a recent encounter reminded him that even the most informed consumer can struggle with the disjointed nature of the American healthcare system.
Like many Oscar members in New York this year, Gabe changed doctors to one in Oscar’s new network. Unlike most members, though, this transition was a bit more complicated: because he receives a monthly infusion of an expensive, specialty medication to treat an autoimmune disease, Gabe also needed to transfer the drug authorization from his old doctor to the new one.
That’s when things got… interesting.
A misadventure with insurance services
Gabe’s old insurer and doctor deemed these infusions medically necessary, but his new doctor couldn’t get authorized to administer his medication until the old authorization was cancelled. On top of that roadblock, his new doctor wasn’t authorized to seek this on Gabe’s behalf, so it fell on Gabe to handle the matter with his old insurance provider.
It seemed like a simple enough task: He dialed the member services number on the back of his ID card. He spoke to the pharmacy department first, who transferred him to the member services department, who transferred him to the pharmacy department, who transferred him to the speciality pharmacy department, who transferred him to the auths department. And so it continued.
After speaking to a slew of different representatives and spending over two hours on the phone, Gabe was finally able to transfer the pre-authorization.
An eye-opening experience at a new doctor
Once his new doctor ordered his medication, Gabe went to the new clinic for his monthly infusion. This time, however, there were two clear differences in his experience.
The first — it was much faster.
Gabe says, “At my previous doctor, they gave me a 30 minute hydration drip before the infusion, which then took another hour and a half or so to administer. My new doctor took 30 minutes to administer the drug, without hydration beforehand, which he said wasn’t required for long term patients on my particular infusion.”
It’s possible his previous doctor was following more conservative care guidelines. The medication Gabe receives can sometimes cause allergic reactions, and slow administration is recommended. However, he’d been on the same drug for over two years—if he was going to have an allergic reaction, it would have likely happened already.
The second difference — the ease of his follow-up care.
“At the end of the appointment, the doctor suggested we check in again in three months. This confused me because the staff at my old clinic insisted my monthly infusions needed to be administered under my doctor’s supervision--which meant an accompanying appointment every month. I told him what I'd experienced in the past, and he laughed. ‘They just wanted to bill your insurance for the office visit,’ he explained.”
Because certain powerful medications should be monitored by a medical professional, it’s possible his old doctor was just being extra precautious by being present herself, beyond the attending nurses. Even so, the economics of the healthcare system aren’t built around the patient, creating misaligned incentives that increase costs and complicate the doctor-patient relationship.
Whatever their reasoning, this policy caused headaches for Gabe in the past. “Sometimes, my old physician didn’t have appointment availability around when I was supposed to have my next infusion, so I was frequently late--—sometimes by weeks--—to receive the medication I needed.” says Gabe.
A convoluted system at work
Gabe’s story will sound familiar to anyone who’s lost their way in the labyrinth of today’s healthcare system.
While a trip to the doctor once meant just that—receiving treatment with a physician to treat a malady and calling it a day—things are more complicated now. Today, the same visit to the clinic involves multiple institutions (the doctor, the medical facility, the drug manufacturer, the pharmacy, the billing office, the insurance company), all of which are disconnected from each other. This makes for an incredibly poor consumer experience.
“The main challenge is the disjointed nature of healthcare,” says Gabe. “Your doctor isn’t adequately equipped to ensure you get the right tests performed, or follow up with you if it doesn’t happen, or ensure your medication gets delivered on time—and they shouldn’t have to. A doctor’s core competency is not complex operations. They’re experts at providing clinical guidance and setting up a care path. But from there, you have to figure things out.”
This confusing experience is all too common. Consumers are left on their own to do research, make phone calls, coordinate record transfers, obtain approvals, and review bills—often without access to the information they need to make informed decisions. It’s an exhausting process, even for a person in great health.
For someone with medical issues, the additional burden of navigating the healthcare system can cause stress that negatively impacts their recovery process. For example, a 2011 study (opens in new tab) from The Ohio State University found that “converging and replicated evidence from experimental and clinical models of wound healing indicate that psychological stress leads to clinically relevant delays in wound healing.”
Nebulous accountability to patients
There are many parties involved when a patient needs care, but no one is directly accountable to or responsible for the patient’s end-to-end experience. Each party contributes one piece to the complicated puzzle that is our healthcare system, but the sum isn’t greater than its parts. Gabe describes it this way:
“It’s like if you went to a restaurant and, for some reason, each part of the meal was prepared by five different kitchens from across the city. Let’s say you get your meal and it’s not what you ordered. The waiter says it’s not his fault because he’s just delivering the food the restaurant provided to him. The restaurant says it’s not their fault because they don’t actually prepare your meal—they just serve it with some nice ambiance. Each of the five chefs that helped prepare your meal can point to another kitchen that’s actually responsible for the foul-up. And the delivery people who brought the food from the other kitchens to your restaurant say it’s not their fault because they just deliver what they’re given.
“What Lovecraftian nightmare is responsible for this terrible restaurant experience? Who do you get mad at in this situation? Who is responsible for solving your problem? Everyone, or no one?
“It’s the system as a whole, and no single player, who’s the villain here,” says Gabe.
A better way forward for healthcare
Despite these systemic challenges, in recent years some organizations are making meaningful changes to improve the patient experience. At Oscar, everything we do is to improve our members’ experience with this complex system through personal Concierge service, easy-to-use care management tools, and simple explanations for every step of a patient’s care.
Navigating the chaos with a team of experts
Each Oscar member has a dedicated Concierge team of care guides and a nurse. When members call, text, or email Oscar, one of their Concierge team members responds. Their team is there to deal with the system on their behalf, connecting all the disparate players to guide a member’s care needs: doctors’ offices, hospitals, labs, pharmacies, medical device providers, billing offices, and more.
In complex situations, Oscar’s care guides and nurses will step in to coordinate everything on behalf of the consumer so they can focus on their health. And since all member interactions reach the same dedicated team, members develop close relationships with Oscar, and Concierge teams feel directly accountable to the members they serve.
“I can’t tell you how much I wish I’d had a Concierge team helping me through this ordeal," says Gabe. "Concierge is really a quarterback, helping people navigate the healthcare system and get the help they need. If they don’t have the answer to your question, they won’t pass you off to another department. They’ll do some research and call you back with an answer.”
Suhaily Feliciano, a Care Guide at Oscar, puts it this way: “We don’t just give you a rep—we give you an advocate. We help people figure all this stuff out.”
“Concierge has a different mandate than member services elsewhere—it’s a mandate of ownership. They’re not just going to pass a member along to another department or narrowly answer the member’s specific question. We instill from the first day of training that this job is nothing like a call center. Our care guides are responsible for making sure their members’ issues are solved.
“That doesn’t just mean instilling a different ethos, though—it also means empowerment. They’re fully plugged into the unique ecosystem of tools we’ve developed at Oscar, so they have better visibility into their members’ health activity, which puts them in a position to deliver better, faster service,” says Gabe.
The system itself is still mind-bendingly complicated, nuanced, and confusing. That isn’t likely to change any time soon. But with a Concierge team to work alongside them, Oscar members no longer face the chaos alone.
Creating dedicated teams to develop trust with members
Gabe’s recent insurance mishap showcases just one of myriad reasons consumers have trust issues with insurance companies. Wanting to call your insurance company before going to the doctor or getting a procedure is atypical. (Let’s be real here — wanting to call your insurance company at all!) How could anyone build rapport with an organization where they never talk to the same person twice, get a straight answer, or feel that the people assisting them actually care about their situation?
Because each Oscar member has a dedicated Concierge team, her care guides are familiar with her health history, doctors, and insurance plan benefits. This helps the team guide members to make more informed decisions than a traditional customer service rep who has more limited, one-time access to a member’s information. Since members always connect with the same four people, they eventually get to know their team on a personal level and vice versa. The member comes to realize their care guides and nurse truly care about them, which fosters trust over time.
Suhaily says, “What we do here makes a difference. Every time I’m able to take something off someone’s plate, it helps. It builds trust over time. Some members request to talk to me specifically, and we form a close relationship.”
Oscar has quantified this anecdotal sentiment with Net Promoter Scores (NPS). Ratings increased 27% for members who had Concierge teams versus the control group.
An evolving system
Gabe’s story is all too common. Many Americans share similar stories of frustration with their healthcare experience, all stemming from the same issues with the broader system.
Still, there’s reason to hope this experience will change. While the industry may move slowly, individual players like Oscar are making changes that are positively impacting consumers. The more healthcare companies invest in a better consumer experience, the less pain everyone will feel when they have to engage with the system in the future.
