简而言之: 为了寻找价值,付款人想要重新定义 pcp在病人护理中的作用.
初级保健定期享有15分钟的名气. 浮华的 headlines herald the arrival of the latest primary care disruptor (Iora, 巴比伦,碳等.),专家们都疯了,然后……兴奋 消散. 亚马逊的 最近 收购onemmedical 重新启动了炒作周期.
但是在后台, many payers have already been executing on a vision to transform their operating models from focusing primarily on healthcare spending to also focusing on healthcare delivery—starting with primary care. 尽管亚马逊被奉为行业颠覆者, payers are better positioned to shift the value proposition of primary care services. Health plans have already built the scale and capabilities to holistically view the patient journey and, 结果是, they have a deep understanding of how and where value can be generated within the delivery system.
为了获得这个价值, 支付者将初级保健置于他们愿景的中心, with lofty ambitions of redefining the role of a primary care provider (PCP). 纳税人 will be placing increased expectations on PCPs and aligning those expectations with incentives to drive value while also rolling out capabilities to support PCPs’ interactions with their 病人.
Primary Care Providers Generate Tremendous Value for 纳税人 and the Patient 他们云顶集团的人群
从付款人的角度来看,初级保健可以是一个来源 巨大的价值. 通过对初级教育的投资,支付者意识到了这一点 care to improve access and foster a stronger patient-provider relationship, they can mitigate unnecessary spending and keep members within their networks.
健康人口
纳税人 want their patient populations to be as healthy as possible; investing in their members’ health leads to fewer high-cost claims. 为此, 研究表明初级保健的有益影响 关于预防医学、人口健康和保健质量. 进一步, the capacity to manage chronic conditions and prevent them from worsening is best achieved through primary care.
积极的医患关系
纳税人 that enable PCPs to have a highly functioning relationship with their 病人 provide the best situation for improving and sustaining member health. Positive experiences are vital to ensuring members stay with their current healthcare insurer, and at the center of a good member experience is the relationship and trust a member has with their PCP. Member retention and decreased churn are critical to high-performing and financially strong health insurers aiming to grow membership and enhance their reputation. 互惠互利的医患关系也有助于 确保流体护理协调这有助于将患者留在支付网络内.
更低的护理成本
初级保健的理想定位是降低总成本 管理 一个病人’s 通过交付系统的旅程. The setting where 病人 receive care has a substantial impact on both quality and total cost. 一个 研究 showed that claims for 病人 receiving care at a hospital outpatient department were 21% higher than they would be for an office visit—and 258% higher for a chest radiography. PCPs can be the principal directors of 一个病人’s care delivery journey, ensuring that their 病人 seek care at the most appropriate site of service possible, 增加积极的健康结果并降低成本.
初级保健也在其他方面提高了表现, 比如只把病人推荐给表现出色的人, low-cost providers that are in network; using thorough documentation to accurately code 病人, thus impacting risk adjustment revenue; and preventing unnecessary visits to the emergency room, 减少医疗云顶集团浪费.
最终, these capabilities and strategies reduce patient and health plan payments in the short term and lower premiums in the long term.
付款人的投资和策略,以建立与pcp的一致性
在很多方面, PCPs share and can extend health plans’ foundational goals—improving care and utilization management, 实现成本控制, 提高会员的整体体验. 纳税人 recognize this and are continuously investing both time and resources to create the proper care alignment and ensure services are appropriately directed to PCPs.
Figure 1 outlines several strategies payers are using to create the proper alignment with primary care practices services, 从更紧密的结盟(直接投资), 垂直集成)到松散的对齐(非正式协作), 改善患者体验)策略.
图1:Payer和PCP对齐策略
图2:自2006年以来,PCP和专科共付额
Source. 对象为
pcp将有机会与付款人合作并保持一致 继续增长. pcp的关键是确定哪一种对齐形式 对他们的组织有意义. 希望被收购可能是,也可能不是 long-term strategic consideration, but expanding value-based care contracts, participating 在新产品中,支持社区健康倡议都是 immediate opportunities for PCPs to align with payers while supporting their 病人.
初级保健中的支付方障碍
尽管付款人做出了努力,但阻碍 会员将不会看到他们的会员资格继续存在.
云顶集团40011官网短缺
第一个障碍是pcp的短缺. 美国医学院协会估计,到2034年, 医疗保健系统将在17年之间出现短缺,800和48,000位初级护理医师. 一个驱动因素是pcp和专家之间的巨大工资差距. In 2021, specialists were making on average about $100,000 more than PCPs. 2021届医学院毕业生的平均债务为200美元,000, 学生们寻求薪水更高的职位是有道理的. 纳税人 and products are increasingly emphasizing the use of primary care, but until medical students are incentivized to seek careers in primary care, 进入仍将是一个问题.
缺乏推荐
除了pcp的日益短缺, 并不是所有的健康计划都需要转诊, which often leads to members skipping the primary care visit and going straight to a specialist. 如果成员和他们的PCP关系不好, it’s even less likely that they’ll get a referral or have a conversation before seeing a specialist. A PCP’s relationships with other network providers can also be a hindrance. 如果供应商没有很好地参与到他们的网络中, 向PCP咨询的成员可能得不到高质量的推荐.
消费者的选择
除了云顶集团40011官网的配备和操作上的挑战, 付款人还可能面临消费者选择方面的障碍. 消费者(e.g., 雇主, 会员)经常改变健康计划, 因此,在某种程度上,支付者和提供者正在走向垂直整合, 会员可能最终会以相同的频率更换他们的PCP, 这会使每个支付者的PCP价值主张边缘化. 考虑到这一点, it is important that both 支付方和pcp co-brand and market their partnerships so that consumers can clearly see the relationship between their health plan and PCP. This can also create added stickiness for both parties that will ultimately drive long-term value.
制定成功的初级保健战略
支付方希望pcp成为患者护理计划的中心 整体的会员体验. 如果操作正确,PCP和 病人、健康计划和专家为所有人释放了巨大的价值 病人旅程中的利益相关者.
然而,支付方不再是被动的利益相关者 care services and are actively looking to increase their value by investing in 他们的交货. 尽管初级保健面临诸多障碍,但支付方还是有实力的 and scale to structure networks and design products that meet consumer demand 同时尽量减少云顶集团40011官网短缺的影响. 更直接地说,纳税人可以 transform the primary care market and will do so at the cost of providers if 没有适当的对齐策略.
重要的是,pcp要主动评估他们的 internal capabilities, capacity, and overall strategy to reconcile with the demands of the market, or else risk being replaced by new or expanded services 这可以由他们的付款伙伴提供. payer-PCP对齐策略 detailed above are excellent starting points for PCPs to assess their care model, operations, and payer partnerships to maximize value for the provider 集团与云顶集团40011官网.
了解心电图
creating mutually beneficial partnerships and alignment opportunities between
支付方和pcp.
编辑: 马特杂粮面包
出版于2022年9月28日