Andrew Yates over at Think Gene has an interesting post suggesting  A Force Fix for Healthcare. The idea is a simple one – all third party healthcare payers (insurance companies) must expose a web service that allows the public to simulate any insurance coverage decision. You put in all the inputs, and you get out a yes or no answer.  He argues that since the decisions are being made by computers and algorithms anyway, there’s no reason that this couldn’t work.

I like the idea in principle – in general, I’m in favor of exposing decision making processes to consumers whenever possible, and enabling smart, motivated people to build tools that streamline complex systems for everyday users. Physicians would love it, too  – much less revenue at risk.

That being said, there are a couple of practical issues. I’m not sure I’d go as far as calling these problems, since they’re surmountable and wouldn’t kill the idea outright.  The core issue is that coverage decisions are not isolated. Take a doctor’s visit as an example. Most insurance companies, including Medicare, won’t cover more than one primary care office visit (for a routine checkup) within a certain time period.  So to simulate the coverage decision accurately for a particular patient, we need to know when their last reimbursed office visit was. With Medicare that information may not be available in real time, and I suspect other insurance systems face similiar problems. You can still simulate, but you have to provide a set of assumptions that will vary on a bill by bill basis.  Doing better may well require a rip-and-replace for Medicare’s systems.

The other issue is that coverage decisions aren’t deterministic, and there often is some medical thought that goes into it. Genetic testing is an excellent example. A few months ago I got to spend a day shadowing one of the attending physicians in the adult genetics clinic at one of the major Harvard hospitals. We spent a lot of time talking about the challenge of getting insurance companies to reimburse for some of these tests. It’s clear that, right now, there aren’t a lot of simple rules that can applied to reimbursement decisions at the cutting edge of medicine. Appropriateness of testing (and it’s expensive testing) is going to depend on a lot of factors, including the makeup of the patient’s extended family.  While I doubt the insurance companies are this sophisticated, a test might be appropriate for a 50 year old woman with three children, but not for a 50 year old with no children. For the former, the test could create intervention opportunities for the kids. For the latter, it may just be informational.

The bottom line: it’s an interesting idea, but I’m not sure if it can really be applied to all coverage decisions, and at a reasonable cost.