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As Insurers Balk on Risk Sharing, Providers Take Charge

Philip Betbeze, for HealthLeaders Media, August 16, 2013

Knowing that taking risk on reimbursement is coming, they're hoping to build momentum by implementing population health strategies with their own employees, for example. They're also implementing their own narrow networks with local employers, in many cases.

But when it comes to negotiations with insurers, too often it's the same old game of negotiating fee-for-service contracts. Even the federal government, with its Medicare Shared Savings program and even the Pioneer program, seems to be moving faster.

Insurers, on the other hand, seem to want to slow-play the game of implementing risk on the facilities they pay, whether they be huge hospital systems or physician practices.

In some cases, these companies, which are presumably being pressured by employers to lower the rate of healthcare cost inflation, are making do with small, limited scope experiments in encouraging pay for performance and risk-based contracting. They're making a reasoned bet that they don't know enough about how risk sharing will pan out to implement it nationwide.

All healthcare is local, it's true, and what works in one geographical area won't necessarily work in another, but employers and patients are getting wise to how much healthcare costs them. They won't wait on insurers forever.


Philip Betbeze is senior leadership editor with HealthLeaders Media.
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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.