According to a Commonwealth Fund report, the US ranks last among high-income countries in healthcare access, efficiency, and equity. Our health system has vast potential and can achieve Moonshot-like outcomes, but it still struggles to address people’s day-to-day needs.

The world’s largest health ecosystem comprises five fundamental stakeholders — patients, payers, product innovators, policymakers, and providers. And while they should work in harmony, they remain primarily disconnected, operating in silos with financial performance as the measure of success. With the fear of economic failure nipping its leaders’ heels, the system prioritizes fiscal responsibility over patients’ healthy longevity. It leads to a “sick-are” over healthcare strategic mindset.

A System Disconnected

While medicine is a “team-support,” the health industry positions its sectors like boxers — each pitted against the other. The concept of a fragmented health system is not new. Nearly 20 years ago, Dr. Alain C. Enthoven, a renowned health economist, argued that the US health sector suffered from a fundamental lack of coordination and misaligned incentives, leading to inefficiencies that primarily burden patients.

In her book Fragmented, Ilana Yurkiewicz, MD, illustrates the real-world consequences of this disconnect. Patients often find themselves bouncing between specialists dedicated to one piece of their patient’s anatomy, grappling with conflicting medical advice, and navigating a bureaucratic maze that often results in disparate, delayed, or denied care.

Economic pressures fueling consolidations and layoffs have led major players to go slow on much-needed ambitious health information initiatives. The much-heralded digital transformation, which promises AI-driven operational efficiency, seamless data exchange, and improved patient outcomes, remains unrealized.

Meanwhile, patients are finding themselves trapped in a complex, hard-to-navigate medical maze where medical records are often inaccessible, treatment plans are inconsistent, payer decisions feel opaque, and pricing remains elusive. The effect is profoundly dehumanizing.

The Patient is Out of the Picture

Financial pressures outweigh the fundamental goal of healing, and the loss of patient focus and a significant decline in empathy remain the system’s most glaring obstacles. This absurd reality is captured in a satirical moment from Yes Minister, where a lawmaker appointed by the UK Prime Minister visits an award-winning hospital — shockingly operating without patients. While comedic, the scene reflects an all-too-real aspect of modern health systems. Administrative structures, insurance approvals, and reimbursement models dictate operations, often sidelining the very individuals who seek care and healing.

As economic priorities continue to reshape industry, hospitals that once promised solutions struggle to sustain themselves, leaving patients increasingly marginalized. While improving patient outcomes should be the central focus of government policymakers, they too often become secondary considerations.

As the US Congress considers budget decisions, cutting Medicaid state subsidies does not mean economically struggling patients will be denied urgent care. Instead, when they seek treatment in the ER, hospitals will absorb the cost. This shifts the financial burden, further straining healthcare systems already operating on razor-thin margins.

Doctor Burnout: Primary Symptom of a Broken System

Physicians enter medicine purpose-centered with a desire to heal, yet the system relentlessly applies administrative and financial pressures that shift their attention elsewhere. Many doctors experience burnout, driven by excessive paperwork, prior authorization hurdles, and unrealistic patient quotas. According to a Mayo Clinic Proceedings study, nearly 63% of physicians report signs of burnout, including emotional exhaustion and depersonalization.

Designed to streamline care, electronic medical records (EMRs) are still a significant source of frustration. Physicians spend hours dealing with complex interfaces rather than engaging with patients. The demand to see more patients in less time — dictated by billing and reimbursement structures — further erodes the doctor-patient relationship, leading to dissatisfaction on both sides.

A 2023 survey by the Primary Care Collaborative and the Larry A. Green Center found that 62% of primary care physicians report not having enough time to adequately meet patients’ needs, which impacts treatment and preventive care discussions.

This dissatisfaction manifests as a breakdown in communication. While effective dialogue between providers and patients across specialties and within the broader health ecosystem is essential for treatment and prevention, patients and physicians struggle to find time to connect.

Burnout is not simply a professional hurdle; it’s a crisis that directly affects patient outcomes. Overworked, exhausted doctors are likelier to make errors, experience lower job satisfaction, and even leave the profession altogether. If the system fails to address professional despair and its causes, the shortage of health professionals will only worsen, limiting access and compromising care.

The Business of Health Over the Health of People

While business considerations shouldn’t take precedence over people, the financial structures underpinning the health sector drive decision-making that deemphasizes people’s health. The silos within the health ecosystem exacerbate this issue, preventing a shared understanding of economic and operational realities, limiting coordinated action and shifting the focus away from the patient.

Insurers prioritize cost control without recognizing the pressures this places on providers. Pharmaceutical companies innovate without fully considering how reimbursement models shape prescribing behaviors. Policymakers create regulations with a limited understanding of their clinical innovation impact. This lack of cross-sector awareness perpetuates fragmentation and inefficiency, and patients ultimately pay the price.

Digital health companies, once hailed as the future of care efficiency and effectiveness, are struggling with financial sustainability, forcing many to pivot or shut down entirely. Biopharmaceutical companies triage drug development pipelines, looking for future medicines with a high probability of regulatory success rather than encouraging research that may fail but illuminate a pathway to even more significant discoveries. Again, it is the patient who pays the price.

The Cost of Failing to Invest in Care and Caring

There is enough blame to go around, and we must stop looking for a convenient villain. If we attack one piece of the ecosystem rather than look at the totality of our problem, we will fail to make meaningful changes.

We can’t throw our health system out and start from scratch; we must find a way to work within and through it effectively. The primary lever that will drive reform of the health system and improve its functioning is bringing everything back into empathetic focus, with the patient at the center of care. Whether we are payers, product innovators, policymakers or providers, we must ask if our actions are built on a foundation of empathy — from heartfelt “care.” First and foremost, we must cooperate in the service of the patient.

The health sector is an industry, but it must be more than that. At its core, it should recognize that we are always people — only sometimes patients. Yet, financial pressures have overtaken its fundamental purpose: healing. This system-wide disconnect erodes trust, drives up costs, and leaves too many without the care they need. Until the key players in the health ecosystem realign around a unified, patient-centered mission, fragmentation will persist, outcomes will fall short, and lives will remain at risk. The stakes are too high to accept anything less.

Unless we build on a foundation based on “how would I feel” empathy, our system will not be built to last. It will be structured to fail.

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JACKSONVILLE, Fla. — Facing an ultracompetitive market in one of the nation’s fastest-growing cities, UF Health is trying a new way to attract patients: a combination emergency room and urgent care center.

In the past year and a half, UF Health and a private equity-backed company, Intuitive Health, have opened three centers that offer both types of care 24/7 so patients don’t have to decide which facility they need.

Instead, doctors there decide whether it’s urgent or emergency care —the health system bills accordingly — and inform the patient of their decision at the time of the service.

“Most of the time you do not realize where you should go — to an urgent care or an ER — and that triage decision you make can have dramatic economic repercussions,” said Steven Wylie, associate vice president for planning and business development at UF Health Jacksonville. About 70% of patients at its facilities are billed at urgent care rates, Wylie said.

Emergency care is almost always more expensive than urgent care. For patients who might otherwise show up at the ER with an urgent care-level problem — a small cut that requires stitches or an infection treatable with antibiotics — the savings could be hundreds or thousands of dollars.

While no research has been conducted on this new hybrid model, consumer advocates worry hospitals are more likely to route patients to costlier ER-level care whenever possible.

For instance, some services that trigger higher-priced, ER-level care at UF Health’s facilities — such as blood work and ultrasounds — can be obtained at some urgent care centers.

“That sounds crazy, that a blood test can trigger an ER fee, which can cost thousands of dollars,” said Cynthia Fisher, founder and chair of PatientRightsAdvocate.org, a patient advocacy organization.

For UF Health, the hybrid centers can increase profits because they help attract patients. Those patient visits can lead to more revenue through diagnostic testing and referrals for specialists or inpatient care.

Offering less expensive urgent care around-the-clock, the hybrid facilities stand out in an industry known for its aggressive billing practices.

On a recent visit to one of UF Health’s facilities about 15 miles southeast of downtown, several patients said in interviews that they sought a short wait for care. None had sat in the waiting room more than five minutes.

“Sometimes urgent care sends you to the ER, so here you can get everything,” said Andrea Cruz, 24, who was pregnant and came in for shortness of breath. Cruz said she was being treated as an ER patient because she needed blood tests and monitoring.

“It’s good to have a place like this that can treat you no matter what,” said Penny Wilding, 91, who said she has no regular physician and was being evaluated for a likely urinary tract infection.

UF Health is one of about a dozen health systems in 10 states partnering with Intuitive Health to set up and run hybrid ER-urgent care facilities. More are in the works; VHC Health, a large hospital in Arlington, Virginia, plans to start building one this year.

Intuitive Health was established in 2008 by three emergency physicians. For several years the company ran independent combination ER-urgent care centers in Texas.

Then Altamont Capital Partners, a multibillion-dollar private equity firm based in Palo Alto, California, bought a majority stake in Intuitive in 2014.

Soon after, the company began partnering with hospitals to open facilities in states including Arizona, Indiana, Kentucky, and Delaware. Under their agreements, the hospitals handle medical staff and billing while Intuitive manages administrative functions — including initial efforts to collect payment, including checking insurance and taking copays — and nonclinical staff, said Thom Herrmann, CEO of Intuitive Health.

Herrmann said hospitals have become more interested in the concept as Medicare and other insurers pay for value instead of just a fee for each service. That means hospitals have an incentive to find ways to treat patients for less.

And Intuitive has a strong incentive to partner with hospitals, said Christine Monahan, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University: Facilities licensed as freestanding emergency rooms — as Intuitive’s are — must be affiliated with hospitals to be covered by Medicare.

At the combo facilities, emergency room specialists determine whether to bill for higher-priced ER or lower-priced urgent care after patients undergo a medical screening. They compare the care needed against a list of criteria that trigger emergency-level care and bills, such as the patient requiring IV fluids or cardiac monitoring.

Inside its combo facilities, UF posts a sign listing some of the urgent care services it offers, including treatment for ear infections, sprains, and minor wounds. When its doctors determine ER-level care is necessary, UF requires patients to sign a form acknowledging they will be billed for an ER visit.

Patients who opt out of ER care at that time are charged a triage fee. UF would not disclose the amount of the fee, saying it varies.

UF officials say patients pay only for the level of care they need. Its centers accept most insurance plans, including Medicare, which covers people older than 65 and those with disabilities, and Medicaid, the program for low-income people.

But there are important caveats, said Fisher, the patient advocate.

Patients who pay cash for urgent care at UF’s hybrid centers are charged an “all-inclusive” $250 fee, whether they need an X-ray or a rapid strep test, to name two such services, or both.

But if they use insurance, patients may have higher cost sharing if their health plan is charged more than it would pay for stand-alone urgent care, she said.

Also, federal surprise billing protections that shield patients in an ER don’t extend to urgent care centers, Fisher said.

Herrmann said Intuitive’s facilities charge commercial insurers for urgent care the same as if they provided only urgent care. But Medicare may pay more.

While urgent care has long been intended for minor injuries and illnesses and ERs are supposed to be for life- or health-threatening conditions, the two models have melded in recent years. Urgent care clinics have increased the scope of injuries and conditions they can treat, while hospitals have taken to advertising ER wait times on highway billboards to attract patients.

Intuitive is credited with pioneering hybrid ER-urgent care, though its facilities are not the only ones with both “emergency” and “urgent care” on their signs. Such branding can sometimes confuse patients.

While Intuitive’s hybrid facilities offer some price transparency, providers have the upper hand on cost, said Vivian Ho, a health economist at Rice University in Texas. “Patients are at the mercy of what the hospital tells them,” she said.

But Daniel Marthey, an assistant professor of health policy and management at Texas A&M University, said the facilities can help patients find a lower-cost option for care by avoiding steep ER bills when they need only urgent-level care. “This is a potentially good thing for patients,” he said.

Marthey said hospitals may be investing in hybrid facilities to make up for lost revenue after federal surprise medical billing protections took effect in 2022 and restricted what hospitals could charge patients treated by out-of-network providers, particularly in emergencies.

“Basically, they are just competing for market share,” Marthey said.

UF Health has placed its new facilities in suburban areas near freestanding ERs owned by competitors HCA Healthcare and Ascension rather than near its downtown hospital in Jacksonville. It is also building a fourth facility, near The Villages, a large retirement community more than 100 miles south.

“This has been more of an offensive move to expand our market reach and go into suburban markets,” Wylie said.

Though the three centers are not state-approved to care for trauma patients, doctors there said they can handle almost any emergency, including heart attacks and strokes. Patients needing hospitalization are taken by ambulance to the UF hospital about 20 minutes away. If they need to follow up with a specialist, they’re referred to a UF physician.

“If you fall and sprain your leg and need an X-ray and crutches, you can come here and get charged urgent care,” said Justin Nippert, medical director of two of UF’s combo centers. “But if you break your ankle and need it put back in place it can get treated here, too. It’s a one-stop shop.”

Author: Phil Galewitz: pgalewitz@kff.org, @philgalewitz

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Amid rising inflation, annual family premiums for employer-sponsored health insurance climbed 7% on average this year to reach $23,968, a sharp departure from virtually no growth in premiums last year, the 2023 benchmark KFF Employer Health Benefits Survey finds.

On average, workers this year contribute $6,575 annually toward the cost of family premium, up nearly $500 from 2022, with employers paying the rest. Future increases may be on the horizon, as nearly a quarter (23%) of employers say they will increase workers’ contributions in the next two years.

Workers at firms with fewer than 200 workers on average contribute nearly $2,500 more toward family premiums than those at larger firms ($8,334 vs. $5,889). In fact, a quarter of covered workers at small firms pay at least $12,000 annually in premiums for family coverage.

This year’s 7% increase in average premiums is similar to the year-over-year rise in workers’ wages (5.2%) and inflation (5.8%). Over the past five years, premiums rose 22%, in line with wages (27%) and inflation (21%).

Among workers who face an annual deductible for single coverage, the average this year stands at $1,735, similar to last year. The average deductible amount has increased 10% over the last five years and 53% over the last ten years.  Workers at small firms (under 200 workers) on average face much larger deductibles than workers at larger firms ($2,434 vs. $1,478).

The modest rise in deductibles may reflect employers’ perceptions about the burden of cost-sharing on workers.  More than half (58%) of employers say that their workers have at least a moderate level of concern about the affordability of their plan’s cost-sharing requirements.  

“Rising employer health care premiums have resumed their nasty ways, a reminder that while the nation has made great progress expanding coverage, people continue to struggle with medical bills, and overall the nation has no strategy on health costs,” KFF President and CEO Drew Altman said.

Almost 153 million Americans rely on employer-sponsored coverage, and the 25th annual survey of more than 2,100 small and large employers provides a detailed picture of the trends affecting it. In addition to the full report and summary of findings released today, the journal Health Affairs is publishing an article with select findings online. The article will also appear in its November issue.

Some Large Firms Do Not Cover Legal Abortions; Others Do But with Restrictions

In the wake of the Supreme Court’s June 2022 decision that ended the federal constitutional right to abortion, states have adopted a range of new laws to prohibit or severely restrict access to abortion, creating challenges for large employers with workers in multiple states.

Among all large firms (with at least 200 workers), one in ten (10%) say that their largest plan does not cover legal abortions under any circumstances. An additional 18% say they only cover legal abortions under limited circumstances, such as in cases involving rape, incest, or health or life endangerment.

In contrast, nearly a third (32%) of large firms say they cover legal abortions in most or all circumstances. Another four in ten (40%) say they were unsure of their plan’s abortion coverage, potentially because their policies were in flux or they were unaware of the details.

With abortion banned or severely limited in some states, 7% of large employers say that they provide, or plan to provide, financial assistance for travel expenses for enrollees who have to go out of state to obtain a legal abortion. Very large employers (with at least 5,000 workers) are most likely to provide, or plan to provide, such travel reimbursements (19%).

Concerns Persist About Adequacy of Mental Health and Substance Use Networks

Among large employers (with at least 200 workers) that offer health benefits to at least some workers, the vast majority (88%) say their plan has enough primary care doctors to provide timely access for enrollees. Substantially fewer say the same about their mental health (59%) and substance use condition (58%) networks.

Nearly one in five (18%) of large offering firms say that they took steps in the past year to increase the number of mental health providers in their largest plan’s network. This includes 44% of the largest employers (with at least 5,000 workers).

On the other hand, one in five (21%) of large offering employers say their plan has limits on the number of covered mental health services, potentially restricting access for enrollees with long-term needs.

“For several years now, the survey has shown that many large employers do not believe that their networks have enough mental health providers to provide timely access to care. In 2023, many large employers, including nearly half of the largest employers, say that they are taking steps to better meet enrollees’ needs,” said Gary Claxton, a KFF senior vice president and director of the Health Care Marketplace Project, the lead author of the study and also of the Health Affairs article.

Other findings include: 

• Offer rate. Nearly all employers with at least 200 workers offer health benefits to at least some workers, though smaller firms are increasingly less likely to offer health benefits as they get smaller. For example, 83% of firms with 10 to 199 employees offer health benefits to at least some of their workers, while just 42% of firms with three to nine workers do so.
• Dental, vision and long-term care insurance. Among firms offering health benefits, most also offer separate dental coverage (91%) – double the share that did so in 2010 (46%). Most also offer vision (82%) insurance, also up sharply since 2010 (17%). Fewer offer long-term care insurance (26%).
• Coverage for gender-affirming surgery. Among employers with at least 200 workers, 23% cover gender-affirming survey in their largest health plan. More than a third (37%) say they do not cover such surgeries, while a large share (40%) are not sure about such coverage. Among the largest firms (at least 5,000 workers), nearly two thirds (62%) cover gender-affirming surgery, many of which expanded the benefit in the past two years.
• Centers of Excellence. About one in five (19%) offering employers with at least 200 workers say their plan includes a “center of excellence” program for specific services, either limiting enrollees to a narrower group or providers or offering lower cost-sharing for doing so. Among these firms, 22% have introduced a new center of excellence program within the last two years. Among firms with a center of excellence program, 45% had a program for joint replacement, 42% for back or spine surgery, 31% for bariatric surgery, 30% for mental health, and 28% for substance use disorders.

Methodology

KFF conducted the annual employer survey between January and July of 2023. It included 2,133 randomly selected, non-federal public and private firms with three or more employees that responded to the full survey. An additional 2,759 firms responded to a single question about offering coverage. For more information on the survey methodology, see the Survey Design and Methods Section.

ABOUT KFF:

KFF is the independent source for health policy research, polling and news.

ABOUT HEALTH AFFAIRS:

Health Affairs is the leading peer-reviewed journal at the intersection of health, health care, and policy. Published monthly by Project HOPE, the journal is available in print and online. Late-breaking content is also found through healthaffairs.org, Health Affairs Today, and Health Affairs Sunday Update.

Project HOPE is a global health and humanitarian relief organization that places power in the hands of local health care workers to save lives across the globe. Project HOPE has published Health Affairs since 1981.

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What patients know about saving money and improving care could provide your hospital with the answers it needs in relation to cost-cutting, improving operational efficiencies, and enhancing patient care. Accessing that information is achieved through the application of ethnography.

Ethnography is an innovative practice that studies the culture and habits of people in specific situations. In healthcare, it can be used to improve patient and family satisfaction and care coordination within a bundled payment model by gaining frontline insights from patients and their families.

Hospitals deliver enormous value to their communities with initiatives to promote health and well-being, prevent disease, and strengthen community partnerships. Building on these relationships with ethnographic techniques enhances that trust.

Your hospital will need a unique patient map and proven strategies to deliver robust and data-rich insights by:

• Targeting the true needs of your patients and their families.
• Revealing the frustrations for patients and families in their experience with your hospital.

These insights inform the implementation of an actionable roadmap with innovative ideas for improvement.

As CMS now reimburses hospitals based on the quality of their patient care, which incorporates the patient experience, I encourage all healthcare providers to carry out this process.

Here are three areas where patient insights can help to deliver cost-saving initiatives. These can be frequently overlooked in the pressured environment in which hospital leaders often find themselves.

The impact of silos in your hospital

The patient journey through your hospital is complex, often involving multiple departments. When teams work in silos, or communication breaks down, the patient experience suffers. Patients also express concern over this process.

The breaking down of silos improves patient flow through your hospital, especially in critical areas, such as the ER. This is a concern for physicians as well as patients, according to the American College of Emergency Physicians:[1]

• 60% said overcrowding forces the diversion of patients with urgent needs elsewhere.
• 28% stated this occurs more than 20 times every year.

Hospital-wide resources management can save your hospital money and improve care. Our comprehensive Patient Journey Mapping™ survey can help to reveal the vulnerable points in your hospital which are increasing costs and impacting patient care.

The patient discharge process

Clear communication at the time of patient discharge means that patients are less likely to be readmitted to your hospital. The average readmission cost per diagnosis back in 2016 was $14,400. Furthermore, it is estimated that one in six patients are now readmitted to the hospital within 30 days of discharge.

Patients want to know what to expect when leaving the hospital after treatment or surgery. Research shows that when patients clearly understand guidance around their medications and care when arriving home, readmissions fall. Frontline insights from your patients will reinforce the need for hospital staff to ensure they fully comprehend all instructions and guidance relating to their discharge.

It should also be noted that we strongly recommend confirming the patient’s social circumstances prior to the time of discharge. Social determinants of health can often cause patients to return to the ER with the same symptoms that resulted in their initial admission.

The overlooked patient billing experience

As I highlighted above, CMS reimbursement is becoming increasingly dependent on patient satisfaction and that satisfaction includes the billing process.

Their experience with billing is often both the initial and final interaction your patients have with your organization. If they believe they are overcharged or their expectations are not met, patient satisfaction suffers.
The extent of the impact on your operating margins is revealed in a study published in October 2019 which found that US healthcare consumers will change their providers over a poor digital experience — which includes online bill payment and e-mailed billing processes[2].

• 41% of consumers would choose another healthcare provider over a poor digital experience.
• Furthermore, 60% of consumers find healthcare bills confusing, which often results in delayed payment and less money to invest in your hospital.
• In addition, that poor experience can lead to lower patient satisfaction scores and lower reimbursements.

Gaining invaluable patient insights into this often overlooked area can help to transform your overall patient experience and save your hospital money, particularly in administrative costs involved in billing.

[1]http://www.ihi.org/resources/Pages/ImprovementStories/BetterPatientFlowMeansBreakingDowntheSilos.aspx
[2] https://www.prnewswire.com/news-releases/study-finds-us-healthcare-consumers-will-switch-providers-over-poor-digital-experiences-300934851.html

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