The system worked, but... Recognizing gaps in care delivery and improvement opportunities

Author’s preface: A few things to keep in mind as you follow my story:

1. The healthcare system worked to save my eyesight.
2. As you read, think about what happens in your practice and what the future looks like.

I use the word system to reflect on how interrelated all things are. Systems management theory has been around since Chester Bernard wrote in Functions of an Executive in 1938. When you enter the healthcare system (“a group of interacting or interrelated elements that act according to a set of rules to form a unified whole”) at birth, you remain part of it until your exit.¹ The healthcare system consists of many components, from physicians and hospitals to support staff and payers. Understanding this interconnectivity helps clarify the role each participant plays and how their actions ripple throughout other parts of the system.

My story

On Sept. 3, 2024, I had my annual exam with my retinal surgeon who had previously treated a detached retina in my right eye and a macular hole in my left eye, although I had no symptoms. This was just an annual visit. During the exam, I could not see half of the eye chart, prompting the need for an angiogram, which was done in the office. The results revealed a stroke in my left eye (the macular hole eye).

The surgeon immediately recommended I go to the emergency department or to see my cardiologist. I walked over to my cardiologist’s office and made an appointment for that afternoon. The cardiologist reviewed my case and referred me to a neurologist to further clarify what might be happening. The neurologist — who is a friend and neighbor — was able to fit me in the next afternoon. His exam indicated a need for a visual field study, specific blood tests and a carotid ultrasound. While the ultrasound was negative, the visual field study and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels indicated an urgent need to see a surgeon for a temporal biopsy due to the fear of blindness.

The neurologist first referred me to an ENT specialist who did not perform the procedure, so I was redirected to a general surgeon. The surgeon saw me the next day, and the biopsy was scheduled two days later at an ambulatory surgery center (ASC).

The biopsy was performed on Sept. 20, and the results came back positive for giant cell arteritis (GCA) on Sept. 25. GCA is rare, primarily affecting those over 50, and is more prevalent in females. Symptoms include headaches and vision issues, such as loss of clarity or double vision. If undetected, it can result in blindness. Emergency treatment includes three days of high-dose infused prednisone in the hospital.

That evening, the neurologist immediately started me on a high dose of prednisone (40 mg) and referred me to a rheumatologist for ongoing management and then ordered additional tests: CT scans of my chest and abdomen and a bone density test, to be done as soon as possible due to the risk of a major stroke. The prednisone dose was elevated to 60 mg. Because I have an issue with diverticulosis, I also consulted my gastroenterologist, who advised sticking with prednisone even with its side effects.

The second and third visits with the rheumatologist were on schedule. The third monthly visit was extended to six weeks due to no openings in her schedule. I am now continually monitored by the rheumatologist with a plan to continually reduce the prednisone dose for at least a year.

The entire process included visits with six physicians with direct face-to-face contacts and four physicians who provided professional review of tests conducted. There were 10 different locations where visits, tests or procedures were conducted — a total of 16 different visits (See Figure 1).

In Figure 1, you see the many systems and subsystems involved in my care. The local hospital and its accountable care organization (ACO) included the neurologist, surgeon, testing services and an ASC, while additional providers operated outside this network. Figure 2 reveals how all these components communicated and interacted. In addition, my insurance coverage includes traditional Medicare, with UnitedHealthcare AARP as my secondary insurer.

Figure 2 uses solid lines to represent direct communication between the source and receiver, while dotted lines reflect communication extending outside the closed system to the open environment. Three of the physicians involved were outside the closed system, and one lacked a portal. The neurologist sent notes to the key referral sources to ensure the process worked.

The hospital-based system features a portal that links all providers, including my PCP, who had not been directly involved in my care at that point. While the retinal surgeon and rheumatologist also have websites and portals, neither one meets the standard set by the hospital system. The cardiologist, however, does not have a website or portal.

Table 1 illustrates the total cost of care based on an analysis of explanation of benefits (EOBs) for both primary and secondary claims. Some payments were reduced due to other arrangements within the hospital system. The total out-of-pocket cost — paid by my primary and secondary insurance and myself — was just over $3,500 despite billed amounts over $35,000. Although other payment models contributed to the final figure, making this not a complete representation of all costs, the outcome was that I can still see!

What happened in the system?

The total time from initial discovery to active treatment was exactly 30 days.

Yes, the system worked — but there were gaps and delays. There were also some significant benefits such as provider and patient participation, relationships and no need for prior authorizations. Even though I can still see and my risk of a major stroke (which could happen to anyone) has been reduced, this experience raised important issues that led me to analyze how healthcare systems operate and share insights to help readers reflect on their roles as both patients and members of the system.

Patient perspective

I am just one of 340 million U.S. citizens and among the 92% of Americans who have health insurance. According to CDC research,²  there are about 1 billion office-based visits annually, with the average patient making between 2.7 and 3.0 visits per year. While I had several visits during this experience, it represents just one of the huge number of encounters that occur each year.

I am fortunate to afford Medicare Parts B ($185 monthly premium in 2025) and D ($46.50 in 2025) premiums, along with supplemental Part B and D premiums. With Medicare Plan F, I have no deductibles, copays or restrictions on which physicians I can see.

My history with the cardiology office led me to go directly from the retinal surgeon’s office to theirs for the in-person interaction, which worked well.

Once the biopsy was deemed necessary, I was advised not to fly due to the risk of losing my sight.

The hospital-based system provided test results, visit updates and messaging.

Coordination among physicians, testing areas and the ASC made it easier to track and understand my care process.

Manager perspective

As a manager within this vast healthcare system, you still play a huge role in dealing with each individual patient. United HealthCare CEO Andrew Witty, in an interview with The New York Times, noted that the system we have is what we have and it is not perfect.³ It was not designed by anyone — it has simply evolved to its current state. The key question is: what role do you play in meeting each patient’s needs? 

The list below offers some insights and poses challenges related to the processes you have in place to meet each patient’s needs. Do you understand each step of the patient journey? Do you use management tools like Lean Six Sigma, project management or the collective knowledge of your team to fix small but critical parts of the healthcare system?

• Analyze the top 20 payers by employer or other metric to create profiles of their prior authorization process, denial patterns, etc. Use this data as a teachable resource for staff and keep it updated as new data emerges.
• The time between requesting the field study and the actual event was a full week. Is this a scheduling issue or a resource availability problem?
• The time to get an appointment with the general surgeon was one day after the neurologist’s referral, and the biopsy was scheduled with the ASC within two days.
• The biopsy, performed at the ASC on a Friday, produced a specimen that was lost in transit to the pathologist. Despite the urgency of the situation, the report came on the following Tuesday after both the surgeon and neurologist followed up. Central scheduling set up the CT scans before the bone density test. However, the bone density could not be completed due to the contrast used for the CT scans and had to be rescheduled. Adding to the disruption, a fire alarm went off during scheduling, requiring further follow-up.
• Lab tests ordered by the neurologist were done within the hospital-based system, while tests requested by the rheumatologist were done at a different lab, resulting in duplicate testing.
• No prior authorization was needed (not being on Medicare Advantage), which allowed for the rapid processing of the tests and procedures.
• The system worked under the neurologist’s management, who later transitioned care to the rheumatologist. However, subsystems like cardiologist scheduling, the ASC-to-pathology handoff and central scheduling caused delays and unnecessary anxiety. My PCP was not directly involved but stayed informed through access to my complete medical record.
• Billing across all providers was timely, and claims were processed without denials.

This analysis has been revealing in many ways. Overall, the process flowed and worked very well. Was this due to my type of insurance, my knowledge of the system, my persistence or pure luck? It would be interesting for practices to analyze their most frequent diagnoses or costliest treatment plans to understand how the system works. This could be accomplished by collaborating with patients to review EOBs and track their flow through the system. Insurance companies have more detailed data than practices; partnering with them could provide a fuller understanding of system workflows and costs, which could benefit both patients and medical practices.

Learn more

• Explore the history and core concepts of Lean Six Sigma and learn to build engaged, high-performing teams while fostering continuous, on-the-job learning — all this and more in Owen Dahl’s latest book, Humanizing Lean Leadership in Healthcare.

Notes:

1. “System.” Merriam-Webster. Available from: https://bit.ly/3WennsH .
2. CDC. “National Ambulatory Medical Care Survey: 2019 National Summary Tables.” Table 1. Available from: https://bit.ly/4aHVEGC .
3. Witty A. “The Health Care System Is Flawed. Let’s Fix It.” The New York Times. Dec. 13, 2024. Available from: https://bit.ly/3Cr3o3o .