Disruptive Model Of Direct Primary Care

The movie fire escape emphasizes that America has the most expensive health care system in the world but is not one of the best in regards to healthcare outcomes and life expectancy. It spends more than what the whole world all together spends on pharmaceutical industry. 75% of the 2.7 trillion dollars were spent on treating preventable diseases which indicate that US health care is more focused towards disease management than prevention. The movie makes a point that there are frequent readmissions and 80% of health care budget goes towards these 20% patients who are frequently readmitted to the hospital due to an existing chronic condition. Health care professionals are paid on the basis of number of procedures carried out on the patient rather than their health outcome. So the focus is not on curing the disease by eliminating the risk factors but merely managing the disease and looking for quick fixes. That is how patients want it too. They want to be cured right away with a pill or surgery but are not really interested in learning the long term solutions and preventative measures.

Since the late 1980s, Medicare has reimbursed physician services using the Medicare Physician Fee Schedule (MPFS), which encompasses 10,000 procedure codes. Each code is assigned resource-based relative value units (RVUs), which are designed to reflect physician work, practice expense, and malpractice expense. To adjust for local differences in cost of living, each RVU is modified using geographic practice cost indexes (GPCIs) and then converted to dollars using a “conversion factor.” This system rewards physicians who produce a high volume of services; not surprisingly, Medicare Part B expenditures have grown rapidly.

Now a statute, the physician/hospital pay for quality, not quantity, public law number: 114-10 signed April 16, 2015 also referenced as H.R.2 —1st Session of 114th Congress (2015-2016), sometimes called the “Permanent Doc Fix” 04/14/2015 : Passed Senate; 03/26/2015 : Passed House (Medicare Access and CHIP Reauthorization Act of 2015, 2015), which defines the payment and reimbursement reform to doctors treating patients with Medicare. This extensive reform includes the CHIP program insuring children and those families that don’t qualify for Medicare but are unable to afford private insurance and is funded by the federal government and individual states.

“The Bitter Pill: Why medical bills are killing us” written by Steven Brill delves into the question as to why medical bills are so high. As Brill begins his research he analyzed bills from hospitals, doctors, and drug companies. Additionally, he interviewed doctors, Medicare and insurance administrators, and gathered patient stories across the nation. He found that the United States spent more money on healthcare than any other developed countries, he stated “We may be shocked at the $60 billion price tag for cleaning up after Hurricane Sandy, [however], we spent almost that much last week on healthcare” (Brill 2013). He also noted “yet in every measurable way, the results our healthcare system produces are no better and often worse than the outcomes in those countries” (Brill 2013). From the charts and graphs that Brill provided shows that the sixty percent of personal bankruptcy filings per year are related to medical bills. Life expectancy in the United States is the lowest amongst the countries that spend most on healthcare, our infant mortality rank is fiftieth in the world, and that one pill cost as much as seven pills in other developed countries such as France. Brill found that in many similar cases, like that ones he presented in the article, Medicare would have at least paid for a small portion of the bill. However, those who don’t qualify for Medicaid and don’t have insurance are often asked to pay excessive prices.

Another reason for the rising cost of healthcare is the cost of physician care, according to the American Hospital Association “the cost of physician care, both to insurance and patients, has risen 1.3% during the past year.” Because of this increase doctors are put in a corner, they are already locked into an agreement with the insurance companies and do not have much ‘wiggle’ room to negotiate fees and rates. So because of this the patients and consumers are forced to pay a much larger sum. Since there are higher costs and the insurers will not cover them, they are distributes to the customers through higher deductibles, co-insurance, and

HMOs are not the only answers to cost control. Most physicians practicing in the United States consider their profession to be very much a form of art (Kleinke). The definition of art infers that within its sphere there are many variations and preferences. After all, one should not ask Picasso to carve like Michelangelo. Physicians too differ in their methods of treating patients. However when needless tests and procedures are done the treatment will cost more. This is waste. Many suggest that cutting waste will lead to a cut in quality. This is not necessarily true. Consider the following: an otherwise healthy forty-year-old male

When Medicare was first established, Medicare adopted the payment methods of Blue Cross Blue Shield which meant that the program was paid hospitals on the basis of their own costs and physicians were being reimbursed by the fees that they charged which caused hospitals and physicians to provide care without boundaries (Anderson et al., 2015). This method caused Medicare to dissipate the budget that was established for beneficiaries to utilize. Now, with the ACA being implemented, Medicare had done an overhaul of payment reimbursement. Medicare is now moving toward a volume to value payment initiative that links payment to patient outcomes, experience of care, while giving providers an incentive to limit spending

Based upon service rates above, it is more cost effective for the physicians to see the patients.

Economic freedom of individual health choices is the overall purpose for Consumer Driven Health Care (CDHC). Freedom of picking the wright policy that fits the specific needs and wants of the consumer. Allowing for the individual to pick the health care provider of their choice is another facet of the program. These choices allow for a more personal approach to finding not only the health care plan but also the provider that the consume may feel the most comfortable with. The end state of which is that the consumer has more control over their health care choices and decisions, rather than

There are growing national concerns regarding the increasing financial burden and of out-of pocket expense for the health care consumer. More specifically, because patients typically see a physical therapist multiple times during an episode of care, the financial burden of copayments may be a deterrent to accessing care. Under certain health plans, copayments for physical therapy services, some exceeding $60 per visit, also can exceed the reimbursement paid by the plan to the provider of care. This cost shift has imposed an unnecessary financial burden on consumers, and restricts access to physical therapy services. High copayments for physical therapy have recently been cited as a reason that some consumers opt to reduce their frequency of

In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals had to manage efficiently the treatment provided to a client and reduce the client’s length of stay (Jacob & Cherry, 2007). Case management, or internal case management “within the walls” of the health care facilities was created to streamline costs while maintaining quality care (Jacob & Cherry, 2007).

No interference from insurance with patient-provider relationship. Direct reimbursement discourages the patient from over-using the plan since their cost increases as the benefits are used. The reason many employers are looking into the direct reimbursement plans is that it will save them thousands of dollars on the insurance company’s processing costs and

Health maintenance organization’s (HMOs) use of the primary care physician (PCP) as the “gatekeeper” initially had MCOs view restrictions as a negative approach to patients’ choices. However, some necessary steps have started to be implemented which reduce unnecessary utilization by enforcing some restrictions.

Health care costs are high for multiple reasons. Inefficiency is happening because doctors lack resources that inform them about their patients’ past tests and prescriptions. This costs time and money. According to Furchtgott-Roth (2009), former chief economist at the U.S. Department of Labor, ten cents of every dollar paid to the doctor goes to his or her malpractice insurance. These rates are so high because there is no cap on the amount of money a doctor can be sued. Doctors even fear being sued for doing “too little” in the patients’ eyes. Because of this, doctors end up running unnecessary tests and prescribing unneeded drugs. Medical News Today acerbates that health care is so expensive because we spend $147 billion per year on problems that

Under capitation, physicians are given incentive to consider the cost of treatment. Pure capitation pays a set fee per patient, regardless of their degree of infirmity, and gives physicians an incentive to avoid the most costly patients (Miller, 2009). Providers who work under such plans focus on preventive health care, as there is greater financial reward in prevention of illness than in treatment of the ill. Such plans avert providers from the use of expensive treatment options. The proponents of this method of payment especially insurance companies argue that when health care providers are not paid extra for additional office visits any associated medical expenses, they are likely to be more conservative with their treatment assessments