You may have read in the local news recently that a major insurance company (a.k.a. “payer”) is proposing to remove one of the Texas Medical Center’s most prestigious institutions from its insurance plan. It is remarkable that a longstanding partnership between a payer and a provider would suddenly be abandoned. Sadly, this move may become more commonplace in the future and will surely limit the number of physicians and hospitals that patients can choose from when seeking care.
As we are all health care consumers, it is important to understand the interdependencies of all of the entities that participate in the economics of the health care system.
The “payer,” as the name indicates, is the entity that pays the providers (doctors, nurses and other medical professionals) and the facilities (clinics, hospitals, etc.) for delivering care. The largest payer in the United States is the U.S. government, which administers the Medicare and Medicaid programs.
The largest private health insurance companies in the country include familiar names, such as UnitedHealthcare, Anthem, Aetna and Cigna. These insurance companies increasingly wield more power and influence as the market consolidates and their respective membership grows.
As the CEO of a company, I believe one of the most important annual decisions I make with my executive team is the selection of our health insurance plan. We carefully choose our plan based on our access to the top providers in our area and the costs of the plan to our company, our employees and their families. Payers, in turn, consider the health care services utilization rates of our employees and their families over the past year. If we are relatively “high utilizers,” our rates will increase; if our utilization was on par or below expectations, our rates may remain the same.
The cost of health care is one of the most serious issues facing our country. Health care spending, as a percentage of the U.S. gross domestic product, has tripled since 1960 and now comprises nearly 18 percent of the GDP. This will continue to create tension between payers, providers and consumers. In addition, the number of people without health care continues to grow and places additional financial pressure on the system.
TMC institutions have long been recognized as top performers in the United States and around the world. Each year, they work diligently to reduce costs while maintaining and enhancing care, but this is becoming increasingly difficult as payers are also reducing the amount of money they are willing to pay for certain services.
As health care consumers, it is important to recognize that the quality of health care is directly related to the training and expertise of the clinicians, the investments an institution makes in research, technology and facilities, and the organizational commitment to all levels of service. In short, not all health care providers are capable of delivering the same quality of care.
At the beginning of each year, all individuals with health insurance should dedicate time to reviewing their health plans. They should fully understand their coverage and the providers they are able to utilize. Finally, every person should schedule an annual physical, which is typically covered by most plans. Nothing in the world is more important than the health of you and your family.
@Marissa_lara14 We're thinking of you, Marissa.
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