Friday, March 1, 2024
HomeHealthWhy Physicians and Health Plans Strive for Value

Why Physicians and Health Plans Strive for Value


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Citizens are fed up with the healthcare system; this is taking place globally. The number of American citizens who cannot afford healthcare is believed to exceed 114 million people. This is just under half of the population (44%). A whopping 93% feel that they do not get the value they paid for. For more statistics, see here.

Healthcare institutions are struggling too. Managing spiraling costs and having to provide quality care is not an easy task, with various strategies having been used in the process. These strategies include electronic records, teaching patients to advocate for themselves, enforcing best practices, attempting to decrease fraud, and finding ways to reduce errors.

The Goal of Healthcare

The goal of healthcare is to provide the best patient outcome at the lowest possible cost. This is value for money and entails quality care and client-centric processes. Currently, the almighty dollar holds sway as profits are chased and patients are still not getting the service that they pay for. More than a third of citizens are labelled ‘cost insecure’, meaning that they meet the following criteria: inability to fund medical treatment, such as occupational therapists in Townsville, and could not pay for prescribed medication in the preceding three months. Additionally, at the time of the survey, they could not afford to see a doctor.

The Quality and Cost of Healthcare

The healthcare system must find the means to improve patient outcomes. This has to be done in conjunction with providing affordable healthcare. Thus, this is a two-prong target where both objectives must be met simultaneously. 

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FRG can help Health Insurance Providers (HIP) with internal audits of claims, recovering overpayments, and staying in the pink financially. Healthcare institutions (HI) also need to watch their bottom line and profit margins. They are subject to audits by HIPs.

Somehow, these conflicting aims need to be managed so that all goals are achieved for patients, members of insurance plans, HIs and HIPs. There needs to be changes to payment structures and outdated service delivery mechanisms. 

The Changes Taking Place in Healthcare

Medicaid and Medicare do not reimburse patients to the same extent as private plan groups. Many hospitals are partnering with HIPs. This tendency has led to many health practitioners abandoning private practice in favor of working out of an HI and receiving a set salary. The long-term aim is to shift from a fee-for-service model to one grounded in performance. It is understandable that this will not happen overnight.

On the Horizon

While change may be slow, several areas for improvement have been identified. The first is to establish Integrated Practice Units (IPUs). IPUs consist of specialists and non-medical employees who collectively manage each patient’s condition within a comprehensive and skilled team. Members may be working out of different sites.

Secondly, patients need to be charged in a more integrated way. For example, currently, stroke victims are charged separately for primary care, various specialists, and several therapists, such as speech and language therapists, physical therapists, and occupational therapists. The cost of treating a stroke needs to be enumerated and implemented. 

Addressing cost structures and improving the quality of service are of primary importance to turn things around.

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Bellie Brown
Bellie Brown
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