Tag: Tech dysfunction.

Evolving and Accumulating Requirements, Example of

For example, consider the most basic issue of coverage: whether a given worker is eligible to claim unemployment benefits. According to the DOL, to answer that question you must figure out, among other things, whether the worker’s “employing unit” qualifies as an “employer.” Under the Federal Unemployment Tax Act, that term originally applied to “employing units” that, “during any calendar quarter in the current or immediately preceding calendar year, paid wages of $1,500 or more” and to “employing units of eight or more workers on at least one day in each of 20 different weeks in a calendar year.” In 1956, that threshold was changed to four or more workers; in 1972, it dropped to just one worker. Today, about half the states use this federal definition, but the others strike out on their own. In Montana, the minimum payroll to qualify as an employer is $1,000 in the current or preceding year; in New York, it’s $300 in a single quarter; in Iowa, any wages at all paid in the current or preceding quarter will qualify. In Massachusetts, thirteen weeks of payroll is enough to be an employer; in Arkansas, it’s having a single employee for ten or more days.

The unemployment department in any given state would have had to update its systems as the federal definition changed, as their own state definition changed, or as their labor agency switched back and forth between the federal and state definitions. Few updates succeed in catching all past references to the former rule, so you will find artifacts of previous regulations strewn throughout documentation and code. That’s probably how the EDD came to have work items for “Stop Payment Alert” and for “Stop Payment Alert—Claim Review” that mean two totally different things. Perhaps some law changed and programmers coded a new work item to fit the new rules, but the original one persisted, most likely because it was still attached to active claims. Everything accumulates.

Recoding America: Why Government Is Failing in the Digital Age and How We Can Do Better
Jennifer Pahlka

Snags in the US Health Care System – NY Times

I saw the common sense that can underlie workarounds when my hospital floor instituted bar code scanning for medication administration. Using a hand-held scanner to register bar codes on medications and patients’ hospital bracelets sounds smart. But then some medications routinely came without bar codes, or had the wrong bar codes, and we nurses weren’t given an easy way to report those errors. Patients’ wrist bands could be difficult to scan and the process disturbed them, especially if they were asleep. The lists of medications on the computer screen were also surprisingly hard to read, which slowed everything down.

But the biggest problem was that the scanning software did not work with our electronic medical records — so all drugs had to be checked off in both systems. This is a huge problem when dealing with patients like those receiving bone-marrow transplants, who might get 20 drugs every morning — some of which are delivered through IVs and come with nonstandard doses. What was already a lengthy process suddenly took twice as long.

The American Medical System Is One Giant Workaround, New York TImes
By Theresa Brown
Ms. Brown is a clinical faculty member at the University of Pittsburgh School of Nursing.

From the comment section:

I am a nephrologist (kidney specialist) who has been practicing for 40 years. I have been forced to use electronic health records by insurance companies and Medicare. If you attempt to read encounter notes from an EHR you realize that the purpose is not to transmit medical information, but rather to optimize coding and billing. I will read a referring doctor’s note in the EHR and be unable to find a section that describes what the doctor is thinking and planning to do to treat the patient. It’s all about diagnostic codes and billing.

—

My insurance company requires that I use home delivery after the third prescription refill. I initiated a change last Thursday. I have contacted the pharmacy through its phone app, Internet, and telephone. I have done the same with my health care provider. I spent a total of two hours working on this during business hours so far with no success. Today, I discovered that the aforementioned move must be approved by my insurance company. That’s right, the same insurance company that requires me to use home delivery is holding up the transfer. It will be at least another 72 hours before the medication is shipped. As a result, I will probably run out before it gets here.

—

It took me 21 months and hours and hours of phone calls and letters to get a cholesterol screening covered by my insurance company. The cash price that the lab was charging: $900. Yes, almost a $1000 dollars for something I could have paid out of pocket less that $60 (which is what insurance covers). The kicker is that $3.78 WAS paid out by the insurance company for the blood draw.

A yearly cholesterol screening is covered item number 8 on my 100+ page insurance coverage contract. It is listed on the first page as a covered item. After dealing with the insurance company for 6 months and having the claim denied 3 times, I was told to appeal. My appeal was denied, 15 months later. As far as I can tell, my insurance company breached state law no less than 3 times in terms of timeliness and inappropriate denials.

The insurance blamed the doctor, the doctor blamed the lab, and the lab blamed the insurance company.