American Health Care Stakeholders

Throughout this blog, I will be discussing the various groups (or stakeholders) that have an interest or concern in our health care system. They fall into three categories: payers, health care providers, and the patients.

The payers and health care providers together make up what I am collectively calling HICUP (BB Brigade acronym for those who are engaged in the “business of health care” in the USA) in this blog. Payers are third-party organizations that pay and are responsible for the charges generated for medical services and products delivered to patients. They are remote groups that simply transfer health care dollars from one place to another. They include private sector employers, state and federal governments, and health insurance companies. The insurance companies– intermediary payers through thousands of health insurance plans– are subcontractors to the other payers. Unlike the individual patient who does “pay” a portion of the medical charges, payers also have control of the flow of the money (negotiating power). I have not included uninsured Americans, who pay directly for all their health care costs, in the payer category because they do not control the flow of money as the other payers do.

Health care providers, largely owned and operated as private sector businesses, include individual health care personnel (nurses, medical doctors, chiropractors, opticians, dentists, psychologists, physical therapists, etc), health care facilities (ambulatory care facilities, hospitals, nursing care and retirement facilities, etc.) and medical products (drugs, medical devices and equipment, etc.). They provide medical services and products for the majority of Americans, directly bill the payers for a negotiated fee, and collect an agreed upon copay/coinsurance from the patient at time of service. Health care providers are also employed in separate health care systems (e.g., Veterans Health Administration) funded and overseen by our federal government.

The patient group includes every individual American who has ever needed health care services. I believe that the patient group (the individual Americans) is the most neglected stakeholder in our health care system! Uninsured patients (11.9% in mid 2015 and shrinking) are given health care services, when they can afford to pay the costs (only emergency medical care is mandated by The Emergency Medical Treatment and Active Labor Act of 1986). While insured patients have third party payers who negotiate for lower costs, the uninsured do not and therefore pay much more for the same services.

Each stakeholder has responsibilities and receives benefits from the health care system. I have made a table below to summarize what I understand these responsibilities and benefits to be.

GroupBenefitsResponsibilities TodayResponsibilities in the Future?
PayersGet paid for administration and management services renderedTo transfer money to medical providers for services and products rendered and deal with problems after the factTo make sure a system of payment for cost-effective, quality, and medically necessary medical care is in place and functioning?
Health Care ProvidersGet paid for services/products providedGet paid for services/products provided Provide medical care for sick patients with an option to exclude patients who cannot payTo provide cost-effective, quality, and medically necessary medical care?
PatientsReceive affordable quality medical care?To seek medical care when needed and to procure health insuranceTo actively contribute to the management of individual health care ("patient engagement")?

This table is a work in progress. In the last column, the future ” responsibilities ” category is meant to set the foundation for affordable quality health care. These future responsibilities are not demanded by any of the stakeholders today. None of the stakeholders is accountable and there lies the problem.

The payers in our healthcare system do not function as a unit with common patient-centered goals and therefore do not share a unified sense of responsibility to the patient. There is no central government mandate (or leadership) specifying they must and in its absence, the individual payers seek their own directions:

  • government payers seek to maintain the integrity of programs (and bureaucratic jobs)
  • employers seek to minimize health care premium costs
  • health insurance companies seek ways to retain maximal health care dollars for themselves

Medical providers, functioning as private businesses, have never had to provide cost-effective services for patients let alone services of any kind (with the exception of patients presented to emergency rooms as mandated by The Emergency Medical Treatment and Active Labor Act of 1986). Medical providers have the right to turn away patients (you have all seen signs in your doctor’s offices proclaiming that Medicaid patients are not welcome) who do not pay as much as others. As businesses, medical providers function often under conflicting financial and quality patient care goals. Health care payments from payers are guaranteed and free flowing, no matter what the quality of care, which is not measured or reported for patients to evaluate. Medical provider’s business success is measured in “quantity” of care and not “value” of care delivered (patient outcomes achieved per dollar expended) as well as by limiting low and maximizing high reimbursement patients whenever possible. Medical providers delivered what the system rewarded. Obamacare is an attempt to connect quality of care with payment.

Lastly, what about patient responsibilities? They are the ultimate beneficiary (or victim if malpractice is involved) of medical care and leaving all management of it to those in HICUP (BB Brigade acronym for those who are engaged in the “business of health care” in the USA)  is a recipe for receiving less than ideal care and usually being over-treated. Patients need to become fully “engaged” in their personal health care before it can truly become affordable and of high quality . How many patients are practicing this today? Not many. This involves a new way of thinking about health care that has not been encouraged by HICUP and requires an educational foundation to be laid and nurtured. It begins with making good eating and lifestyle choices that prevent sickness before it happens and ends with actively contributing to health care choices when sick. Patient engagement will be discussed in detail throughout this blog.

Continue reading at Who Needs a Healthcare Brigade?