Consumer-Driven Health Plans Pose New Set Of Challenges
In health care insurance today, everyone wants change.
Brokers and health insurance customers are clamoring for more choice, increased access to providers, and less intervention in personal health care decisions.
Employers are seeing the highest health care premium increases since the early 1990s, plus dwindling value in managed care solutions. Theyre pressuring insurers to contain premiums.
Now, the resolve to have change is about to be tested, for insurers are responding with a barrage of choice-based product features. For instance, carriers are dismantling preauthorization programs, gatekeepers, and closed panel networks, even as they roll out next-generation systems built upon choice.
This next-gen trend goes by the name of “consumer-driven health care.” The distinguishing element in such plans is that they shift control and responsibility to the customer.
Certain pro-change advocates might be happy to hear about all this. However, the new systems present challenges of their own. Therefore, the old adageto be careful what you wish for, you just might get itseems very apropos.
Here are some examples of the new systems, and some of the challenges they pose:
Tiered Co-Payments. The trendsetter of tiered co-payments is prescription drug benefits. Today, most health plans use tiered or variable co-pays as a means of managing drug costs.
In tiered plans, the customer makes a small co-payment for generic drugs and a higher co-pay for brand name preferred (i.e., formulary) prescriptions. For non-preferred drugs, these plans only make partial payments or no reimbursement at all.
Tiering is also being applied to hospital preference. Patients who want to receive treatment at a specialized but expensive hospital, such as an academic medical center, will pay a higher co-pay. For those who go to a lower-cost community hospital for the same procedure, the co-pay would be much less, or nothing at all.
Similar co-pay programs are being implemented for specialty physician services and outpatient surgical procedures.
Furthermore, these plans are segmenting providers, based on cost or quality measures. In addition, consumers are being asked to choose between generic and brand name, and between University Hospital and Community General.
The challenge: Its the patients responsibility to be a prudent buyer of health care services.