How do changes in payer systems drive utilization in health care service organizations

What is single-payer health reform? Patients no longer face burdensome premiums, copays or deductibles, even as they gain free choice of physician and hospital.

How do changes in payer systems drive utilization in health care service organizations

Without correcting the fundamental structural flaws in health care financing, overall health care costs will remain poorly controlled. Though our clinical outcomes are mediocre by comparison [1], the average per capita cost of health care in the United States is twice that of other modern nations [2].

The patient-centered medical home or PCMH (sometimes referred to as medical home, or advanced primary care) is an innovation in health care delivery designed to improve patient experience, improve population health, and reduce the cost of r-bridal.comgh its origins date back to (in pediatrics), the medical home concept has grown over the past decade, with nearly public and private. A National Public Health and Hospitals Institute (NPHHI) survey asked hospitals that collected race and ethnicity data whether they used the data to assess and compare quality of care, utilization of health services, health outcomes, or patient satisfaction across their different patient populations. Health insurance payers have a variety of healthcare reimbursement plans, and carry contracts with individual practices and health systems (contracts that are periodically renegotiated, which is just one source of change within the system).

Increasingly, these costs are being borne by patients and government, driving personal bankruptcies and ever more austere public policies [3, 4].

Under the ACA, 30 million people will still have no coverage [5], and countless more will have inadequate coverage [1]. The declining actuarial value of plans offered by employers means that the ACA will still leave those who need health care with financial hardships and high rates of bankruptcy, in spite of the subsidies for premiums and out-of-pocket expenses.

An insurance policy with a 70 percent actuarial value would, by definition, leave patients responsible for 30 percent of the overall cost of the care on the list of covered services. Many other medically necessary services, such as home and long-term care, dental treatment, hearing aids, and basic vision care, will not be covered and are therefore not captured in out-of-pocket maximums.

Health insurance exchanges are envisioned to function like many familiar online marketplaces, such as Travelocity or Amazon. At the moment, only a handful of states have fully committed to implementing exchanges [6].

States that do not implement an exchange will have an exchange implemented for them by the federal government, assuming Congress allocates the appropriate resources. They will be available on January 1,for uninsured individuals and small groups to compare insurance plans.

Comparison shopping makes sense when buying a product like an automobile, about which individual preferences vary widely. With health insurance, however, we all need the same thing: We need to be able to select our own physicians, but the complexities of selecting an insurance company distract us from genuinely beneficial health care activities.

Given the currently dominant role of insurers in our health care, the exchanges are a step forward. In the 6 years since Massachusetts adopted legislation very similar to the ACA, the cost of health care has continued to drive patients into financial ruin [7]. The state has achieved nearly universal coverage, but, like the ACA, its legislation has yet to effectively address cost and sustainability.

Its newly enacted cost-containment law relies heavily on unproven measures such as capitated payments and wellness programs, offering little promise of success [8].

How do changes in payer systems drive utilization in health care service organizations

We will not solve our health care crisis as long as private insurance plays a dominant role. We should correct the flaws of the current Medicare program and extend this coverage to all age groups.

A second problem is that the uniquely American plethora of private insurance companies drives a squandering of resources. Legions of staff manage independent computer systems.

Each insurance company devotes an enormous number of personnel to responding to emerging regulations from a variety of disparate governmental programs. The intent behind those regulations could instead be implemented once, in a single system servicing the entire country.

Medical groups and hospitals all dedicate staff to managing within this environment, eroding their profits and contributing to a demand for higher reimbursement.NBER Program(s):Health Care, Health Economics Doctors and hospitals in the United States serve patients covered by many types of insurance.

This overlap in the supply of health care services means that changes in the prices paid or the volume of services demanded by one group of patients may affect other patient groups.

There were a number of different health care reforms proposed during the Obama reforms address cost and coverage and include obesity, prevention and treatment of chronic conditions, defensive medicine or tort reform, incentives that reward more care instead of better care, redundant payment systems, tax policy, rationing, a shortage of doctors and nurses, intervention vs.

Multiple, disparate definitions for population health management abound. Yet, population health management should be defined the same way public health was defined years ago by C.-E.A. Winslow, founder of the Yale Department of Public Health, as: “the science and art of preventing disease.


Health systems, which include people, institutions, and resources that deliver healthcare services to meet the health needs of target populations, are evolving with the market and delivery innovations to meet the challenge of managing healthcare risk through a growing emphasis on primary care, integrated care models, and pay-for-value.

One of the key factors driving changes in healthcare is the concept of patient-centered care.

Learning Objectives

In this new approach, patients are treated with dignity and their needs for privacy and individual expression respected.

Intelligently planning capital investments to match community health care needs is the key to aligning utilization of services with public health priorities. According to the Physicians’ Working Group for Single-Payer National Health Insurance, “Capital spending drives operating costs and determines the geographic distribution of resources.

Oregon Health Authority : Oregon Health Authority : State of Oregon