6. How should healthcare plans balance the interests of all the enrolled patient

Question

6. How should healthcare plans balance the interests of all the enrolled patients with the interests of a patient who has special medical needs and extraordinary expenses? 7. In the interest of maintaining a successful practice, should a physician refuse to provide care for patients who are uninsured or minimally insured? 8. Consider the question of ethics that arises when we ask ourselves if we are reducing unnecessary tests, as the HMOs and others believe we should, or if we are limiting tests for patients who really need them.

Explanation / Answer

Hlthcr pln

Th ptins PPO pln is trditinl hlth pln with cpymnts, cinsurnc nd dductibls. Mmbrs hv ccss t brd ntwrk f physicins nd hspitls ntinwid. Th pln dsign ffrs tw lvls f cvrg – highr lvl f bnfits pply fr ntwrk srvics, nd lwr lvl f bnfits is vilbl fr nn-ntwrk srvics with highr dductibls. Th pln includs full spctrum f cvrd srvics nd dirct ccss t spcilists withut th nd t gin pprvl frm primry cr dctr.

Mmbrs hv th frdm t s ny hlth cr prfssinl r visit ny fcility in ur ntinwid ntwrk, including spcilists, withut rfrrl nd withut chsing primry physicin. Mmbrs cn chs srvics utsid f ur ntwrk, which r nrmlly t highr cinsurnc, nd/r dductibl lvl.

Msuring th cst f cr

Fr fild in which high cst is n vrrching prblm, th bsnc f ccurt cst infrmtin in hlth cr is nthing shrt f stunding. Fw clinicins hv ny knwldg f wht ch cmpnnt f cr csts, much lss hw csts rlt t th utcms chivd. In mst hlth cr rgniztins thr is virtully n ccurt infrmtin n th cst f th full cycl f cr fr ptint with prticulr mdicl cnditin. Instd, mst hspitl cst-ccunting systms r dprtmnt-bsd, nt ptint-bsd, nd dsignd fr billing f trnsctins rimbursd undr f-fr-srvic cntrcts. In wrld whr fs just kp ging up, tht mks sns. xisting systms r ls fin fr vrll dprtmnt budgting, but thy prvid nly crud nd mislding stimts f ctul csts f srvic fr individul ptints nd cnditins. Fr xmpl, cst llctins r ftn bsd n chrgs, nt ctul csts. s hlth cr prvidrs cm undr incrsing prssur t lwr csts nd rprt utcms, th xisting systms r whlly indqut.

T dtrmin vlu, prvidrs must msur csts t th mdicl cnditin lvl, trcking th xpnss invlvd in trting th cnditin vr th full cycl f cr. This rquirs undrstnding th rsurcs usd in ptint’s cr, including prsnnl, quipmnt, nd fcilitis; th cpcity cst f supplying ch rsurc; nd th supprt csts sscitd with cr, such s IT nd dministrtin. Thn th cst f cring fr cnditin cn b cmprd with th utcms chivd.

Th bst mthd fr undrstnding ths csts is tim-drivn ctivity-bsd csting, TDABC. Whil rrly usd in hlth cr t dt, it is bginning t sprd. Whr TDABC is bing pplid, it is hlping prvidrs find numrus wys t substntilly rduc csts withut ngtivly ffcting utcms (nd smtims vn imprving thm). Prvidrs r chiving svings f 25% r mr by tpping pprtunitis such s bttr cpcity utiliztin, mr-stndrdizd prcsss, bttr mtching f prsnnl skills t tsks, lcting cr in th mst cst-ffctiv typ f fcility, nd mny thrs.

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