Yesterday, we discussed whether or not, Rush Limbaugh is worth $400 million. My point being, "your opinion has no bearing on whether or not he is worth $400 million.
Today we'll talk about the 3P's of healthcare: Payer….Provider…..Patient. Whose opinion matters most?
In a perfect world, the answer is easy, "THE PATIENT We do not live in a perfect world..
Some quick definitions:
Provider- usually a physician or hospital who invoices the payer. Providers can be a nurse or therapist, if they bill directly or indirectly through an agency. Usually the services are billed for by the facility, and so they are not normally considered providers.
Patient- the person getting treatment. At times, the relationship extends to family members who make decisions or collaborate on decisions with the patient.
Payer-usually an insurance company or the government; such as Medicare or Medicaid. Occasionally, the patient may be the payer.
We would like to think that providers carry great weight. However, they are constrained by insurance preauthorization, small reimbursements, drug formularies, government and insurance approvals and other parameters that do not always allow them to make the decision that is in the patient's best interests.
Then the patient has the most clout! This would be nice; however in the great majority of cases the patient doesn't pay the bill. It's usually pay by insurance or Medicaid. Interestingly, when the patient wants to pay cash, often obstetricians do not want to accept it.
What if the patient understood how little the obstetrician gets paid from HMO or Medicaid. What if the patient says to the doctor: "I will pay you extra, give me more personalized care.” If the doctor takes the money he/ she would be breaking the law.
I guess the patient does not have much clout.
That leaves us with the payer! The payer can decide to pay more for a physician than midwife, pay for hospital birth but not a homebirth, pay for an anesthesiologist but not a labor coach, pay for infant formula. But not lactation consulting, or the payer can decide to put you, the provider ,in-network BUT require you to carry malpractice insurance which costs over $100,000 per year.
So, who has the most clout? By now, the answer is easy. So how can activists effect change? The answer... learn to speak the language of the payer!!!
Next week, more about hybrid birth centers, also "Are Death Panels. Becoming Reality?"
Have a great weekend
Alan
Alan@birthconference.org
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"The payer can decide to pay more for a physician than midwife, pay for hospital birth but not a homebirth, pay for an anesthesiologist but not a labor coach, pay for infant formula. But not lactation consulting, or the payer can decide to put you, the provider ,in-network BUT require you to carry malpractice insurance which costs over $100,000 per year."
ReplyDeleteThanks for that particular insight. It was immediately clear to me that the payer would have the most clout (the local and organic foods movement has drilled that into me), but it never occurred to me the choices that our current payers make. I'm glad there are people like you and others who can speak the language of the payer and lobby for payment for doulas, childbirth educators, homebirths, midwives, and birth centers.