Addressing the Healthcare Challenges in United States in AI Era

According to a Gallup study, seven out of ten people view the current healthcare system as being in a state of crisis or facing major issues that have lasted for over three decades. Despite spending more on healthcare than any other high-income nation, the United States continues to bear a heavier burden of chronic diseases.

Key Participants in the Healthcare System

Before discussing the main challenges in US healthcare management, it is useful to review the different participants in the system.

The primary participants include:

·       Providers: Healthcare organizations that deliver services by offering various treatments, employing professionals, and managing facilities.

·       Patients: Individuals who seek healthcare services and receive medical care, treatments, and other services as primary recipients.

·       Physicians: Medical professionals who are directly involved in patient care, diagnosis, and treatment.

Core Issues in US Healthcare Management

In 2021, the US healthcare industry was valued at around $4 trillion, roughly $12,000 per capita, and it is projected to exceed $6 trillion by 2028. Yet, the system shows negative productivity gains, meaning that additional investments yield lower GDP returns.

Several factors contribute to this situation, including:

Physician Burnout

Physician burnout is a serious concern affecting both patient care quality and the well-being of healthcare professionals. A major contributor is the inefficient use of time, often linked to administrative duties and electronic health record (EHR) systems.

For patients, long waiting times, rushed appointments, and limited direct interaction with doctors can lead to dissatisfaction and a feeling of being underserved. Similarly, for doctors, excessive paperwork and data entry overwhelm them. As a result, physicians now spend more time on administrative tasks than on direct patient care, leading to high fatigue, stress, and reduced professional satisfaction.

Using tools like SOAPsuds, which employs AI for automated transcription, can streamline patient interactions and ease documentation challenges, thereby supporting more efficient care.

Revenue Leaks

Administrative inefficiencies such as duplicate paperwork, billing errors, and delayed reimbursement contribute to revenue losses. The absence of smooth communication and coordination between various healthcare providers leads to fragmented care and hampers accurate billing.

Studies have shown that hospitals in the US lose about $12 billion per year due to poor communication, often caused by outdated technologies, departmental silos, and similar issues.

Moreover, limited access to comprehensive patient histories often results in incomplete profiles, causing suboptimal care. Delays in diagnosis and treatment not only affect outcomes but also lead to financial losses from complications that could have been avoided.

Rising Healthcare Costs

It is well known that healthcare in the United States is expensive, with costs continually rising. In 2018, spending reached approximately $3.6 trillion, nearly $11,000 per capita, and CMS projections suggest national expenditures will hit $6.2 trillion by 2028 due to:

Technological Advancements: While new medical devices and tools enhance diagnosis and treatment, their high research, development, and implementation costs drive up spending.

Increase in drug prices: Pharmaceuticals have faced public criticism as retail prices for more than 450 prescription drugs increased by 5.2% on average in 2020, outpacing inflation.

Waste of Resources: Inefficiencies such as unnecessary tests, procedures, or treatments waste valuable resources, including time, labor, and supplies. Reports indicate that staff inefficiencies in preventing wastage significantly contribute to cost overruns, forcing providers to charge more for basic services while shrinking their operating margins.

Healthcare Disparities

A Deloitte study suggests that barriers to access may cost over $1 trillion by 2040, but more importantly, the true cost is the preventable loss of lives. Many Americans cannot afford quality care or even regular access to caregivers.

Factors contributing to these disparities include:

·       Insufficient Insurance Coverage: Limited finances and minimal health plans force individuals to skip crucial preventive screenings, dental visits, and child vaccinations, which can have lasting negative effects on health. Many health systems have begun programs to support underinsured or uninsured patients.

·       Stigma and Bias: Prejudice based on ethnicity, immigration status, gender identity, sexual orientation, and other factors remains common. Experts note its damaging effect on marginalized groups’ willingness and ability to seek counseling, transition-related care, and other essential services. Even unintentional bias from clinicians, based on outdated information, can make patients feel unwelcome and reluctant to return.

·       Language Barriers: With one in every five US households speaking a language other than English, meeting language needs is a growing concern. When patients and clinicians do not share a common language, it can affect care quality, especially in hospitals. While family members often act as interpreters, this can lead to miscommunication and errors.

Data Security Threats

Federal mandates have led over 59% of hospitals in the US and Canada to adopt Electronic Health Records (EHRs) for storing patient data, with more providers following suit. However, these systems come with their own challenges.

·       The first issue is the cost of acquiring this software. EHR systems are expensive and add to the rising costs of healthcare delivery. Recent years have seen the use of AI-based tools help optimize healthcare operations.

·       Migrating from old IT setups demands resources for system transition.

·       Training for caregivers and administrative staff to use these new systems requires both time and investment.

Data privacy also remains a major concern. Between 2009 and 2020, breaches exposed over 70% of patient records, exceeding those in the financial and banking sectors.

Compared to other industries, healthcare is less prepared for cyber-attacks. Reports indicate that hackers have targeted over 100 million patient records, surpassing the figures in financial sectors.

According to a statement from a director of operations at a healthcare service provider, limited funding and budget constraints have made many healthcare organizations easy targets for attackers who exploit these vulnerabilities.

SOAPsuds’ CARE platform helps by offering robust security with remote deployment within organizational firewalls.

Approaches to Addressing Healthcare Management Challenges

Modern healthcare offers exceptional diagnostic capabilities and life-saving therapies. However, experts warn that a single error can lead to cascading, potentially dangerous outcomes in an ecosystem of interconnected yet fragmented platforms, protocols, and participants.

Researchers have used the Swiss cheese model as an example to illustrate daily occurrences in healthcare. They explain that each slice represents a person or process that, when functioning well, prevents errors. However, if the imperfections align, repeated errors can occur, sometimes with life-threatening consequences.

Strategies to reduce errors, standardize systems, and improve healthcare access include:

Integrated Delivery Models

Systems that consolidate care delivery with insurance plans are better positioned to align incentives and adjust quickly. A study from December 2020 showed that integrated providers experienced a lower impact during the pandemic.

Integrated systems can also redistribute patient load by shifting patients between facilities, regions, and caregivers, as well as between providers and insurers. They can share knowledge and best practices quickly.

The integrated approach links the cost of providing care with that of insuring it in ways that benefit both insurers and providers.

This model benefits both parties because when healthcare costs decrease, both save money; when the system and insurance are separate, cost-cutting tends to favor insurers rather than the health system.

For instance, one healthcare system owns a nonprofit health plan, while another collaborates closely with various partners. Despite different methods, integrating quality care and coverage yields mutual benefits.

Value-Based Care

Value-based care improves quality of life and corrects misaligned incentives, such as paying physicians based on the number of procedures rather than outcomes. This approach can reduce costs by making care more accessible and maintaining patient health, thereby reducing the need for repeated treatments.

For example, one provider’s emphasis on value-based care helped reduce prices for patients insured through a federal exchange by 2% to 3% over the past three years.

Value-based care also enables providers and insurers to implement new technologies that traditional volume-based systems cannot support. One healthcare organization is working with a medical school to launch a new educational program focused on population health, aiming to keep communities healthier.

Other strategies that have helped implement value-based care include:

·       Reforming teams and workflows: Once panels are aligned, teams supporting physicians must be reformed and equipped for the new care model, with updated processes and regular meetings to address care gaps and patient needs.

·       Restructuring provider panels: Ensuring that providers have a sufficient number of patients under value-based contracts to make changes both financially and clinically viable, with a balanced mix of healthy patients and those with chronic conditions.

·       Educating providers and teams: It is essential to educate all involved on the key principles of value-based care, regardless of their role size.

·       Aligning financial incentives: Incentives should aim to maintain patient health rather than simply increasing revenue.

·       Employing innovative technology: Tools that connect disparate data sets and apply complex algorithms can unlock the value of healthcare data. For example, SOAPsuds’ advanced AI system can streamline medical coding, reduce errors, and maintain up-to-date documentation.

Technology and AI Integration

Artificial intelligence is increasingly influencing healthcare delivery and administration. Along with machine learning, AI can boost efficiency in routine tasks such as patient intake and scheduling, allowing staff to focus on more complex issues while saving time and money.

SOAPsuds provides a way to enhance operational efficiency by automating labor-intensive tasks like medical coding and documentation. This reduces manual errors and frees up resources for other needs.

Other benefits of AI in healthcare management include:

·       Enabling doctors to complete administrative tasks more quickly, freeing up time for patient care.

·       Helping administrators predict staffing needs for more effective scheduling.

·       Allowing some administrators and insurers to use big data analytics and AI to forecast health risks and track disease outbreaks.

Moreover, telehealth—using electronic information and telecommunications for long-distance care—brings specialists such as neonatologists, neurologists, and cardiologists to rural hospitals without the need for patient transfers to larger facilities.

Patients can remain in their communities, supported by local networks, with most compensation directed to the local hospital. This benefits not only rural hospitals but also small towns where hospitals are major employers.

However, these tools are not a cure-all. To maximize their potential, cross-functional teams of healthcare professionals, scientists, nurses, researchers, and tech experts must work together.

Providers must also address security challenges, particularly those arising from insufficient personnel training. Numerous cases of leaked health records have occurred, mostly due to unintended disclosures by staff.

The Final Word

Even a small misstep in managing healthcare data can lead to long-lasting and severe consequences. Such errors may not be detected for years, and by that time, it could be too late.

This is not just about one person or one condition; it is a vast effort. The healthcare management system depends on the collaboration of skilled individuals, advanced technology, and a deep sense of care.

Every piece of data, every diagnosis, every prescription, and every interaction is a vital element that must be stored and managed properly. In healthcare, there is no room for mistakes or complacency.