The balancing act between doctor reimbursement, premium costs


In the post-healthcare reform era, insurers face a new challenge--how can they pay doctors enough so they continue accepting their members while decreasing premiums to make them affordable for consumers? 

Insurers' attempts to shift some risk onto providers, through accountable care organizations, bundled payments and patient-centered medical homes, for example, cause administrative burdens for doctors, resulting in some denying care to patients with exchange plans, reported WNPR.

If that happens, consumers may buy health insurance they can't use to receive medical care.

"I think it could lead potentially to this kind of distinction that there are these different tiers of quality of care," Kevin Counihan, director of Connecticut's health insurance marketplace, told WNPR. "That's been something, at least in our state, that we're trying to work against. And the carriers are, as well."

Ken Lalime, CEO of the consumer oriented and operated plan, Healthy CT, said it's especially difficult for insurers to pay doctors enough while keeping consumer premiums low.

"Every time you increase payments to providers, you have to offset that with increased reimbursements from the consumer," Lalime said. "So there's this balance between how much do you want to cost to provide that service and how much you can pass along in your premiums rates. It's a balancing act."

Bob Russo, a radiologist and president-elect of the Connecticut State Medical Society, says low rates and administrative burdens could make the Affordable Care Act a financial loser for many providers. 

One approach insurers might consider taking is to design programs with comprehensive incentives that reimburse for the entire workflow, FierceHealthPayer previously reported.

To learn more:
- read the WNPR article

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