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As Insurers Balk on Risk Sharing, Providers Take Charge

Philip Betbeze, for HealthLeaders Media, August 16, 2013

And guess who's at the end of that chain of responsibility? Health systems, as they seek to obtain the patient's portion of the responsibility for the bill, which seemingly grows each year with higher copays, deductibles and "coinsurance." That strategy, if you can call it that, has a limited shelf-life.

One CFO told me that high deductible health plans are generating not only declining volumes for a variety of inpatient and outpatient services, but also "a level of hate" from patients toward the hospital or health system, which is left to collect the patient's share of the bill.

Indeed, hospitals, physicians, and outpatient facilities are often obligated through their commercial contracts to attempt to collect that portion.

Not that hospitals and health systems are particularly enthused about moving from fee-for-service reimbursement to sharing risk on quality, utilization and outcomes, among other metrics, but in many geographical areas, they seem to be getting little cooperation from payers in testing risk-based payment strategies.

Why? According to hospital and health system CFOs, payers say they aren't ready.

The lack of progress isn't attributable to the hospitals and health systems themselves. Indeed, many aren't waiting for insurers to implement risk sharing into their contracts, and instead, they're experimenting on their own—especially those that already own health plans.

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3 comments on "As Insurers Balk on Risk Sharing, Providers Take Charge"


Phyllis Kritek, RN, PhD (8/19/2013 at 1:16 PM)
Pleased to see you covering this important development. It has been my sense that during the 1990s in particular, third party payers become the 800 lb. gorilla in health care. Many health care professionals felt powerless to address the shift in risk and power that left clinicians flummoxed. Being held hostage by profit driven insurers has benefitted neither the patient nor the health care professional. One of the most interesting aspects of the Affordable Care Act is the provision requiring insurers to cap profits.

bob sigmond (8/19/2013 at 11:57 AM)
AS money for health care becomes scarcer and scarcer, the function of insurers in the marketplace will become more and more dependent on their ability to share risk with providers, without excessive shifting of the risk back onto the insured patient and the patient's family. The obvious way for the insurers to proceed is to take over the complete management of the risk from the provider organizations. Insurers can contract with a provider organization to take over the complete pricing, billing and collection function by paying the provider organization a guaranteed single monthly check, based on a collaboratively developed annual budget, with close collaborative oversight, includng any necessary adjustments during the contract year. This arrangement guarantees the prvider organization from experiencing a negative bottom line, while doing away with unneeaary adversarial collection and utilizatiion problems, and with the provider organization no longer having any ivolvement at all with fees for service. Initialy, adventureome nsurers shouldl have little trouble staffing up to provide the neesary mony and services to a few demonstation provider organizations which are having increasing problems with growing negative bottom lines. Such orgnizations that don't want to close down will find that they will have less trouble maintainig their identity in close collabration with an insurer than with a welcoming provider organizaation looking to control a larger market. Such an adveenturesome insurer will do extremely well by helping the provider organiaiton to rduce expenditures and also by doing a much better job with collecions and with negotiations wih all the other third party payers. For details abot how the contracting insurer becomes involved in helpig the proovider organizaiton to reduce expeditures while provider income is increased, contact Robert Sigmod at 215-561-5730 or e-mail at bob@sigmond.us. I hope to hear from you. Best regards, Bob .

Todd (8/18/2013 at 10:38 AM)
All healthcare is NOT local. Tell that to Elisabeth Rosenthal or the guy who went to Belgium for surgery in the NY Times article.