Introduction:
Tremendous increase in health care
services have been observed in recent times. Heath care has become
so costly that it has gone out of capacity of a common man. This is
one of the biggest concern for service providers.
Managed Care Organizations (MCOs)
are under tremendous pressure to control health care costs.
Physician
Reimbursement:
It has been identified by many
scholars and researchers that physician reimbursement absorbs a big
portion of heath care cost in the U.S. Managed care has their own
rules and regulations for reimbursement.
Different
methods that MCOs uses to
reimburse providers for health care services:
Health plans have four plans for
paying physicians these include:
- Fee-for-service:
According to this plan physician is reimbursed based on service or
test they have provided to patient as per the charges of the local
area.
- Discounted
fee-for-service: According to this plan physician is
reimbursed based on service or test they have provided to patient
after deducting pre -determined discounts aplicable in local
area.
- Capitation:
According to this plan physician is reimbursed based on fixed
amount per enrollee rather than service or test or on monthly
basis.
- Salary: According
to this plan physician is reimbursed by paying monthly or weekly
fixed amount rather than service or enrollee basis.
Apart from above three payment
adjustments are also concerned with physicians reimbursement, these
are as follows:
- Withholds,
- Bonuses, and
- Retrospective utilization
targets
Reimbursement for services vary based on
the type of MCO models:
There are several models of health
maintenance organizations, some of the common models are as
follows:
- Group
model: Under this model contracts are made between groups
of physicians and MCO’s . Under this contract a set fee is decided
for physician for providing patients with different health services
in central location.
- Individual
practice association (IPA): Under this
model contract is made between MCO and private practice physician
to provide services and negotiated fees is paid for it.
- Network
model: Under this model contract is made between variety
of group of physicians and other physicians that fall under network
of care within referral patterns.
- Staff
model: under this model physicians work under salaried
arrangements and provide exclusive care for enrollee.
- Preferred provider
organization (PPO): Under this model contract is made
between medical care providers and MCO. Covered persons are
provided wit benefits for nonparticipating services providers.
The
situations in which
member/patients pay directly to
MCO:
- The patient or the member are self
pay patients,
- Patients whose benefits are either
deductibles, or out-of-pocket limits,
- Patients with co-payments,
- Payment for non-covered
services.
In my opinion the
reimbursement impacts the way
care is delivered to the patient in
following manner:
- The payment methods are designed to
affect treatment patterns.
- Reimbursement impacts the process,
cost, and outcomes of care for plan enrollee,
- Incentives provided by managed care
impacts the treatment patterns.
- Behaviour of providers while
treating patients is also impacted by the manner of
reimbursement.
I believe that such a influence of
reimbursement an heath care is not a good. Although it is helpful
for one who can afford it to gain advantage from this pattern. But
for those who cannot afford managed care organizations, it becomes
tough.
References:
- McMenamin, Peter. Future Research
and Policy Directions in Physician Reimbursement. Health Care
Finance Rev. 1981 Spring; 2(4): 61–75.
- Bundorf, MK; et. Al. Impact of
Managed Care on the Treatment, Costs, and Outcomes of
Fee-for-Service Medicare Patients with Acute Myocardial Infarction.
Health Serv Res. 2004 Feb; 39(1): 131–152. doi:
10.1111/j.1475-6773.2004.00219.x.