NR_552 Week 3 Discussion, Select Patient Paid Services

Select Patient Paid Services NAME Chamberlain College of Nursing NR 552: Economics of Healthcare Policy Dr. Poirier DATE The cost of covering all medical services demanded by participants of healthcare insurance plans is calculated into the overall cost of premiums for all participants. To maintain or lower premium costs, should insurance companies deny coverage for some healthcare services? Which services would you recommend become patient-paid-only and why? Week 3: Select Patient Paid Services Health insurance is a contract or an agreement between an individual and a health insurer to cover his or her medical expenses (Kim, 2013). The insurer pays all or part of the medical expenses depending on the type of insurance plan one subscribes to (Kim, 2013). The introduction of the Affordable Care Act in 2010 greatly expanded the number of Americans covered by health insurance by over 20 million people (Eibner, 2013). However, concerns over the skyrocketing cost of insurance have emerged. Because the cost of covering all the medical expenses of the participating individuals is calculated by taking into consideration the overall cost of premiums for all the participants, health insurers have the option of denying coverage for some health care services to keep the cost of premiums low. I concur with this option. To keep the cost of premiums low, it makes more sense for insurers to deny coverage for some health care services. These can be non-emergency services like getting a doctor’s appointment or getting drug a prescription. These non-emergency services can be made to patient-paid only because they are usually cheap and the patient can usually plan for their payments. The net benefit is lowering the total cost of the insurance premium. However, according to the Affordable Care Act of 2010, coverage for pre-existing conditions like cancer, diabetes, and asthma must never be denied (Bodenheimer, 2012). Coverage for emergency services like accidents must never be denied too. To conclude, a clear framework between individuals and health insurers can provide for shared responsibilities where the individuals can pay low premiums and make out-of-pocket payments for non-emergency services like drug prescription and doctor’s appointment. The insurer can then come in and cover crucial medical costs like surgery. References Bodenheimer, T., & Grumbach, K. (2012). Understanding health policy. New York City: McGraw Hill Professional. Eibner, C., Cordova, A., Nowak, S. A., Price, C. C., Saltzman, E., & Woods, D. (2013). The Affordable Care Act and health insurance markets: Simulating the effects of regulation. Rand health quarterly, 3(3). Kim, J., Braun, B., & Williams, A. D. (2013). Understanding health insurance literacy: A literature review. Family and Consumer Sciences Research Journal, 42(1), 3-13. PROFESSOR RESPONSE TO POST: If certain non-emergent situations are denied, will patients seek them out in a timely fashion or wait until they become emergent and then seek out ED care? How can we determine if care is truly optional? And who should make that decision? I agree there are certain situations that may be truly optional, but I want us to start thinking about how decisions are actually made. Dr. Poirier, I learned that Anthem Blue Cross Blue Shield (Anthem BCBS), one of the country’s largest health insurance plans, already has implemented a no payment for non-emergent use of the emergency department (ED) policy in the states of Georgia, Indiana, Missouri, Kentucky, New Hampshire, and Ohio (Daly, 2017). Anthem BCBS stated in letters sent to policyholders affected by the policy change, “Save the ER for emergencies. Or you’ll be responsible for the cost,” (Anthem Blue Cross Blue Shield, 2017). The letters were sent out by June 1, 2017, and informed Anthem BCBS policyholders they will be responsible for any incurred ED cost if the visit ends with a diagnosis for something that isn’t emergent. Furthermore, in the letter, Anthem BCBS members are encouraged to utilize urgent care centers, for non-emergent conditions listed as back and joint pain, cold symptoms, sprains or anything requiring an x-ray (Anthem BCBS, 2017). Members are also informed to use a retail clinic for minor allergic reactions, bumps, cuts & scrapes, rashes, and sore throat symptoms ray (Anthem BCBS, 2017). Anthem’s ED program aims to add greater cost sharing to try to reduce the trend in recent years of inappropriate use of ERs for non-emergencies. The policy only applies to large employer fully-insured health plans and self-insured employer plans that opted to participate in the program. The policy does not apply to Anthem's Medicaid and Medicare populations. The argument that many health care providers and lawmakers have against this policy change is that patients can’t be expected to self-diagnose their medical conditions. Most patients lack the medical knowledge and training to determine, for example, the difference between abdominal pain that is life-threatening and abdominal pain that isn’t. Furthermore, many believe this policy violates the Prudent Layperson Standard. The Prudent Layperson Standard requires health insurance companies to cover visits based on the patient’s symptoms, not the final diagnosis (American College of Emergency Physicians, 2018). Anthem BCBS encourages its policyholders to utilize its own online doctor visits and 24/7 nurse hotline to help members gauge the nature of their illness or injury and find other local care options ray (Anthem BCBS, 2017). In February 2018, Anthem revised the initial policy to include some exceptions. Those exceptions to the policy include provider and ambulance referrals, services delivered to patients under the age of 15, visits associated with an outpatient or inpatient admission, emergency room visits that occur because a patient is either out of state or the appropriate urgent care clinic is more than 15 miles away, visits 8 a.m. Saturday and 8 a.m. Monday, and any visit where the patient receives surgery, IV fluids, IV medications or an MRI or CT scan (Christ, 2018). Reference American College of Emergency Physicians. (2018). Insurers denying emergency room care. Retrieved on July 24, 2018, from Anthem Blue Cross Blue Shield. (2017, May 11). Save the ER for emergencies - Or you’ll be responsible for the cost. Retrieved on July 24, 2018, from Christ, G. (2018, March 11). Anthem's new ER policy has area patients, medical professionals worried about emergencies. Retrieved on July 24, 2018, from Daly, R. (2017, June 7). No-pay policy for non-emergent ED use spreading. Retrieved on July 24, 2018, from RESPONSE TO PEER POST: Najiba, I discovered that with higher health insurance deductibles and rising out-of-pocket costs, there is a growing trend of patients opting to pay cash for health treatments or service versus using their health insurance carrier. Patients are asking for discounted prices in return for up-front payment and an agreement not to submit the claim to their insurer. The cash pay option instantly cuts healthcare costs for both the consumer and the provider by eliminating the fees and premiums associated with insurance carriers, as well as lowering the cost of providing health care by not having to pass along the costs of staff and their associated benefits, and the cost of a medical payment default. Reduced fees for paying cash are more common for diagnostic procedures, such as CAT scans, X-rays, and ultrasounds. However, patients paying cash up front are also getting better deals for certain lab work, prescription drugs, out-patient services and surgeries, and therapeutic services, such as physical therapy. Integris Health, the largest health system in Oklahoma, cash-up-front prices are significantly lower, as much as 70 percent lower, compared to the insurance prices (Butcher, 2016). For example, Integris provides an X-ray for $98, an ultrasound echocardiogram for $687, and a bilateral screening mammogram for $220 (Butcher, 2016). Reference Butcher, L. (2016). Offering Up-Front Cash-Pay Prices. Revenue Cycle Strategist, 13(2), 2-3.