https://www.cms.gov/healthplan-price-transparency/plans-and-...
Longer term though we should move away from the fee-for-service model based on providers submitting claims for service codes. A value-based care model where provider organizations bear at least some financial risk and are accountable for patient outcomes will probably work better for everyone.
If I can't get this, there's no price transparency. Of course it's even worse than this in practice, since not only can no one tell me my out-of-pocket cost for a service I'm about to purchase, they can't tell me what the negotiated rate is going to be, and it could be over a year before anyone can tell me either the negotiated rate or my share of the negotiated rate. (Odds are it will take at least a month and these figures will be renegotiated multiple times before I get a bill.)
https://www.cms.gov/healthplan-price-transparency/consumers
Reimbursement rates are negotiated between payers and network providers at most once per year. Rates don't change monthly.
They made a little progress toward it but the providers are fighting it every way they can. Apparently one of the methods is to use many different codes for the same thing so they can't easily be compared. You need to get to the point where it's like a price comparison service; your doctor tells you to get a scan and you get a list of every service in the country that offers it, sortable by both price to you and distance from your house. They should also eliminate the premise of "in-network" and just have all providers publish their prices and insurers publish the amount they cover in your region.
> A value-based care model where provider organizations bear at least some financial risk and are accountable for patient outcomes will probably work better for everyone.
It would probably be better to combine them, i.e. you get primary care your way but when primary care wants you to get a scan or take a medication you have competing providers. Lumping the entire network into one entity is likely to lead to market consolidation and then inefficiency.
I'm not sure what you mean about different codes for the same thing. The health plan MRFs all use the same CPT/HCPCS codes. Each code has a unique meaning.
Health plan member portals also have online shopping tools where you can do price comparisons for every network provider within a certain distance. So what you're asking for pretty much already exists, although many consumers aren't aware of this.
What's to stop providers cherry-picking who they treat? Who's going to treat the patients who are high risk? That will ruin the outcomes metric?
I'm not disagreeing w/ the theory of your proposal. I haven't - yet? - seen how it can actually work.
https://www.cms.gov/priorities/innovation/innovation-models/...
For ACO agreements between provider organizations and commercial payers, the parties can negotiate any contract terms they like. The agreements are usually confidential but payers aren't naive about this stuff and are fully aware of how to protect their financial interests against cherry picking by providers.
> The ratio of those two numbers is the efficiency of the American insurance model.
The ratio of those two numbers is quite divorced from the efficiency of an insurance model.
On the one side, this would count wasteful spending on unnecessary tests or overpriced services as an efficiency improvement because proportionally more money is going to providers. On the other side, if insurers better at preventing fraud have lower premiums and therefore get more customers and make more money, that would count as "inefficiency" and the fraud prevented would also count as inefficiency (because that money went to "providers"), even if the net result is less fraud and lower premiums.
That isn't to say that the US system is efficient. It's clearly quite broken. But its brokenness is because the government has been thoroughly captured by the industry -- which is the providers as much as the insurers -- and they oppose any measures that would improve actual efficiency because the inefficiency is their profit. Which is why the US system costs more than the systems in other countries regardless of whether the other countries use public or private systems.
An efficient regulatory system for a private insurance market would be something like, a schedule of service codes where each provider is required to publish a fee schedule representing the uniform fee paid by all institutional insurers, eliminating the overhead of "negotiating prices" (a major source of inefficiency) in favor of price transparency and allowing patients and insurers to choose a provider on the basis of price and distance, while still subjecting providers to competitive pressure because people would naturally favor providers with lower fees. But the existing US system doesn't do that at all.