In the world of healthcare, a good deal of the conversations surrounding improving treatment methods and outcomes focus on the relationship between the payer and provider. The payer-provider relationship is always evolving, especially in the transition from fee-for-service healthcare to a value-driven model emphasizing chronic care.
This transition presents many challenges leading to tension between payer and provider. The reason for this tension is simple enough: providers must justify their treatments so payers will reimburse them. If that resolution doesn’t occur in this transition process, the patient will suffer the most by not receiving the proper care and possibly absorbing the financial burden.
The ultimate goal of most providers is to be certain a patient receives the care they require to get better. However, the fact remains providers can be paid more the longer a patient is in treatment. These competing goals of patient care and making money create a concern that some more unethical providers extend care beyond what is necessary to improve their bottom line. It’s also understandable that a payer would want to spend as little as possible on a patient, while still ensuring the appropriate amount of care is delivered. After all, there is also a bottom line when it comes to healthcare reimbursement costs.
This struggle to find a balance between treatment and price sometimes takes place while the actual needs of the patient are being overlooked. That’s not to say that both parties aren’t justified:
Needless to say, there are negative consequences to this often contentious back-and-forth between the two parties. Moreover, this neglect of focusing on the patient, rather than how much their care costs, leads to a health care culture where patients are viewed more as a case or file number than as a person.
Patients have little control over their own care. It’s the responsibility of the payers and providers to work together to bring the patient back into the focus of patient care. So, how do we do that?
In terms of patient needs, the most obvious is to get healthy while not being crippled financially. Depending on the individual, high healthcare costs can affect both the patient and their entire family. It’s important to remember that when a person faces the need for treatment, it doesn’t affect them alone. Every member of their family is negatively impacted through financial burdens, emotional duress, and the time the individual must be away from their family and work while in treatment. This is especially true if they are part of a joint family policy.
It’s not just patients that need to be considered, but also how the difficulty of treatment impacts the family unit in general. This impact on families can manifest in many ways. For example:
Even though patients and their families are limited in what they can do, the best thing someone who is facing the difficulties of the healthcare system can do is be an advocate for themselves, or for a loved one who is receiving care. It’s important that a patient knows their rights, especially their rights related to what is provided by their insurance company. In order to understand what is actually provided, they will have to reach out and have their healthcare costs explained to them.
If patient care is mediocre, a patient will see no change in their services if they aren’t pushing for better care. As with all supply and demand, if a patient is demanding good care the market will adjust to provide it. Unfortunately, it’s the responsibility of the patient, or their family members, to ask appropriate questions or express concerns that might arise regarding their healthcare services, treatment methods, and costs. Seeking out a provider that has a track record of providing good care and reasonable costs will improve the experience.
Patients should find a provider who will work for them, even if that provider isn’t in network. However, seeking an Out-Of-Network (OON) provider can be a tricky process for patients. Many times, patients seek out OON treatment providers who are not the best fit for the patient from a financial standpoint, but appear to be the best option for the patient's particular treatment needs. Choosing to go OON may be as a result of that particular provider’s reputation, trusted referrals, or effective marketing techniques. Rather than redirect the patient to a place that would be more financially viable, some providers will instead make a one-time agreement with the payer. One-time agreements are most often more costly for the patient and sometimes the payer as well.
Costs, payments, and reimbursement
Everyone understands that medical practitioners deserve to be paid. They’re highly skilled, highly trained specialists who save lives. There’s no question about that. However, it's all too common that the cost and reimbursement discrepancies between providers and payers cause patient care to take a back seat to the bureaucracy of healthcare.
Ultimately, money is the big question -- what costs should be covered and how much is too much? Unfortunately, bad players exist throughout the healthcare space and make the situation much more complicated. While we’d like to believe that all providers are upholding a common ethical standard when treating patients, that isn’t always true. There are those who manipulate the system for monetary gain at the detriment of patient care. This could be from unnecessary treatments to erroneous charges and everything in between.
For these reasons, it is a good thing payers put checks and balances in place. While one erroneous charge may seem inconsequential, a single charge left unchecked, applied to multiple patients over a long span of time, can snowball into astronomical costs in the form of super high premiums and deductibles. It’s understandable why payers are so unwilling to freely give money, without a burden of proof and efficacy, with the type of precedent it sets. As a result, to the detriment of patients and their families, providers spend less time in treatment and more time on administrative tasks to ensure their treatments are approved.