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Mechanics of Healthcare Financing in the Post-ACA Era

Research the internet, the OCLS, and other sources, including the Bible, to support your position for your discussion.
Describe two common pricing strategies used by health care organizations. What is the difference between public utility regulations and market-based comparisons? Explain your answer.
What are the effects of critical drivers on health care organizations\' prices?
Describe the five types of health plans and distribution of health benefits to employees. What are the implications of each?
Why does utilization management play such an important role in pricing and service decisions under capitation?
Your initial response should be 150 to 200 words in length for each question and include at least one academic source that is properly cited.

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Mechanics of Healthcare Financing in the Post-ACA Era 

Usually, healthcare organizations rely on public utility regulations and market-based comparisons for their pricing strategies. Under public utility regulations, healthcare facilities rely on price guidelines from the government through regulations such as Medicare. Here, the government tries to protect its citizens from manipulation by healthcare providers as highlighted in Leviticus 25:17 that, “do not take advantage of each other, but fear your God.” Contrastively, market-based comparisons involve analyzing the market to determine healthcare price. According to LaPointe (2018), healthcare facilities in markets with few competitors have substantially high prices than their peers in highly competitive markets.

Critical drivers of healthcare, including clinical quality, the success of patient outcomes, the efficacy of healthcare systems, and patient safety might influence healthcare organizations' prices. Here, care providers tend to justify their high prices to the quality of care provided. However, there is a lack of enough evidence linking high prices to high quality (Hostetter & Klein, 2018). The lack of price transparency makes consumers unaware that they can receive high-quality services from lower-cost providers.

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The five types of health plans include health maintenance organizations (HMOs), preferred provider organizations (PPOs), exclusive provider organizations (EPOs), point-of-service plans (POS), and high-deductible health plans (HDHPs) (Goodell, 2020). Under HMOs, a patient has the least ability to choose his/her care providers and must have a referral to see a specialist. On PPOs and EPOs, patients have moderate freedom to choose their providers compared to the HMOs, but they do not require a referral to see a specialist (Goodell, 2020). A POS blends an HMO with a PPO and offers patients more freedom to select their care providers than an HMO and a primary care doctor involved in taking care of the patient and referring him or her to specialists when necessary (Goodell, 2020). On the HDHPs, patients have to pay high out-of-pocket costs than other plans, but they get access to a health saving account to help pay for care.

Utilization management (UM) plays a critical role in pricing and service decisions under capitation for several reasons. Under capitation, the government ensures that patients do not receive suboptimal care through under-utilization of care services. The capitation approach ensures that patients pay for care services depending on the range of services received and the period taken (Alguire, 2020). Using UM, the government can evaluate the appropriateness, efficacy, and medical necessity of services offered to patients (SmartSheet, 2020). As a result, physicians remain at financial risk for the services they offer to patients hence minimizing any unnecessary care services that might lead to an increase in the cost of healthcare.

 

 

References

Alguire, P. (2020). Understanding Capitation. American College of Physicians: https://www.acponline.org/about-acp/about-internal-medicine/career-paths/residency-career-counseling/guidance/understanding-capitation

Goodell, S. (2020). Different Types of Health Plans: How They Compare. WebMD: https://www.webmd.com/health-insurance/types-of-health-insurance-plans

Hostetter, M., & Klein, S. (2018). Health Care Price Transparency: Can It Promote High-Value Care? The Commonwealth Fund: https://www.commonwealthfund.org/publications/newsletter-article/health-care-price-transparency-can-it-promote-high-value-care

LaPointe, J. (2018, May 15). Location, Market Competition Influence Hospital Price Variation. https://revcycleintelligence.com/news/location-market-competition-influence-hospital-price-variation

SmartSheet. (2020). An Introductory Guide to Utilization Management in Healthcare.  https://www.smartsheet.com/content/utilization-management

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