“The current value network in healthcare” - how current employer-sponsored insurance packages result in general hospitals getting used as primary care providers and why out-of-network care is so expensive
“Relative abilities to reduce costs and prices” pg 201 - how physician guilds have captured the reimbursement system and keep out Physicians Assistants and Nurse Practitioners
“Relative abilities to reduce costs and prices” pg 202 - summary of how Medicare pricing is determined
“Employers as integrators” pg 203 - overview of how and why employers are incentivized to improve healthcare outcomes and pricing
General physician stats
Percent of physicians work in private practices: 54% (Kane, 2019)
Percent of physicians who are owners in a private practice: 41%
Number of physicians in practices of varying sizes: 35% in <5; 20% in 5-10; 13% in 11-24; 7% in 25-49; 15% in 50+; 9% in hospitals (Kane, 2019)
“There are more than 9,000 billing codes for individual procedures and units of care. But there is not a single billing code for patient adherence or improvement, or for helping patients stay well.” (pg 150, The Innovator’s Prescription)
The average annual turnover for members in health plans is 17%, ie., each patient is a member for roughly 5-years. This disincentivizes preventative care for issues that manifest outside a short (<5 year) timeframe. (pg 206, The Innovator’s Prescription)
What percentage of practices store credit card information for automated billing?
What percentage of practices charge coinsurance up-front, before the procedure?
How much do claim clearinghouses charge?
How are hospitals collecting data in order to accurately price services (for value-based reimbursement)?
How are PCPs incentivized to be gatekeepers in HMOs/ACOs?
How many self-insured employers directly employ physicians to handle care coordination (or non-physician care coordinators)? Why or why not? Do any TPAs offer this?
Who is running Amazon’s healthcare initiatives? What complementary businesses do they need to exist (to create the value network) to provide their services?
Review “Competition in Health Care: It’s Evolution over the Past Decade”, Health Affairs (2005) - discusses capitation systems and the problem with it being an approach to value-based care