Home Financial responsibility No winners, just losers and survivors amid payer issues

No winners, just losers and survivors amid payer issues


Healthcare is not a one-size-fits-all industry. Current and projected labor markets in health care and other industries in the United States are experiencing labor shortages that are driving up wages for skilled workers.

The healthcare industry is different from other industries. Health care does not operate in a free market where the prices of goods and services are self-regulated by buyers and sellers, based on supply and demand in a competitive market.

Health care revenues are largely set by the government, with Medicare and Medicaid, as approximately 65% ​​of the patient-paying composition is paid by the government, and the remainder is paid by insurers using government payment like bogey. However, on the labor and supply side, health care is subject to free market forces and health care is unable to pass on the cost of labor and other increases due to the fixed payment system.

As a result, overall healthcare operating margins, which averaged 2% nationally before the pandemic, deteriorated to negative operating margins regardless of the impact of payments. supplements to the American Rescue Plan Act.

According to the Center for Health Care Quality and Payment Reform, 892 rural hospitals are at risk of closing, 35% of hospitals and health systems defaulted on their obligations or loans in 2021, 73 hospitals have closed since 2011 and about 1,000 hospitals have consolidated or merged in the past decade.

The United States spends more on health care than any other developed country due to higher prices for goods and services. Health care costs in the United States consumed 18.8% of gross national product in 2021, and the median cost per capita in the United States is $9,892 compared to the median cost per capita of $4,033 for other developed countries. A growing share of healthcare provider revenue now comes directly from patients. Over 75% of patients with employer-sponsored coverage are enrolled in a health plan with an annual deductible, and over 50% of covered patients are enrolled in a high-deductible plan. The average family plan has an average annual deductible of at least $8,000.

Several factors contribute to bad debts and charitable care, which continue to rise, resulting in a negative financial impact on health care. There is a growing number of uninsured (11% of those aged 65 and over in 2020) and underinsured people who spend more than 10% of their annual income out of pocket or whose deductible is greater than 5% of their annual income. The average annual income for a family of four is $67,521, and most health insurance plans have a family deductible of $8,000 per year. These issues have led many patients to incur bad debts and exacerbated the situation for healthcare providers by leading to significant loss of coverage. According to a Commonwealth Fund survey, 6% of US citizens insured in the first half of 2020 lost their coverage during the pandemic.

Healthcare financial advisors have faced challenges obtaining accurate information to identify and verify patient coverage, determine likelihood of patient payment, assess eligibility to enroll eligible patients for financial assistance , collecting and assisting in developing a payment plan.

Patients should be prioritized promptly for follow-up by billing staff as they are likely to pay their balance or who may be challenged to meet their financial responsibility and are assigned financial assistance and/or payment plans. Staff should ensure they support and communicate the payment process throughout the experience, making it less stressful and fair for all patients.

The method of administering benefits is increasingly complex. This change in financial responsibility, coupled with the unprecedented economic conditions associated with the pandemic, has had a major impact on the loss of volume and payments from healthcare organizations.

This situation is untenable. If the United States does not develop and support new models of health care delivery and payment that affect quality and cost, we will become even more dependent on government intervention that will lead to socialized medicine (insurance national disease). Government intervention will ration services and control providers, payers, medical intervention, technology, access and patient choice.

As the healthcare sector heads towards a crucial inflection point over the next decade, much more needs to be done to transform and ensure that the products and services provided will continue to play a vital role in the delivery system. health care. There is a need to actualize the commitment to transform and optimize the industry to accelerate the growth and development of the delivery of high-quality, cost-effective care with a commitment to clinical excellence and personalized patient experience . The healthcare industry must consider repositioning strategic options and combinations that comprehensively integrate cutting-edge technology and clinical methods, investing in people and providing seamless access to prevention, diagnosis and treatment of all diseases in patient-friendly settings. .

There is a need to rethink healthcare delivery models and payment systems to ensure they can meet growing and challenging market demands. Payers must also commit to designing and supporting insurance schemes that emphasize quality and cost. The healthcare industry must adapt to technological, environmental, social, governmental and patient/consumer market changes that impact their day-to-day financial and operational initiatives. Innovative strategies that need to be considered include the creation of ambulatory care as a strategic business unit within regional health systems, the establishment of a larger “system” through shared and coordinated clinical service lines, and the adoption of retail strategies.

It’s time for ingenuity and innovation. Now is the time to try new approaches and new ways to deliver health services more cost-effectively. Healthcare leaders must seek new ways to better position themselves and proactively manage their future.

Healthcare industry leadership must focus solely on the broad mission of improving healthcare delivery and patient outcomes by investing in growth strategies and driving continuous innovation, while controlling costs to survive.

The healthcare industry should work together, with Congress, to consider legislation and programs that help improve the education and training of healthcare workers; improve access to vital prevention, diagnostic and treatment services for patients, such as mental health, addictions, primary care, telemedicine, home services and value-based payment programs in the fee-for-service framework; and promoting total cost of care agreements on the part of payers and other legislative proposals that impact the future survival of the health care delivery system.