The Business of Healthcare

Health literacy

The business of healthcare is an interesting beast. It has been described as miraculous, uncertain, opportunistic, a right, and even an art form. Semantics aside, healthcare is one of the most significant industries in any country worldwide, and represents almost 50% of America’s GDP.  Miraculous indeed.  

The impact that this industry has on our lives has been largely dictated by what the government deems necessary, and the balance between what we deserve and what we can afford. You see, the government has a huge amount of influence on how and when insurance companies should pay clinicians for services or products. Private insurance uses government pay schedules to set policy and payment rules for their own plans. These ‘fee schedules’ are voluminous and complex, making them virtually impossible to understand or apply. As well as being overly bureaucratic, they are a bulwark to the progressive methods we need because they enable obfuscation by our healthcare industry.

But there is hope. With incredibly tight regulations and rules that dictated payments (which often amounted simply to wanton paperwork filing), the clinical side of the healthcare business has been paralyzed by uncertainty and fear over loss of profits for far too long. However, the most recent change in the government’s approach, despite being about 30 years overdue, has become the driving force. Emerging from the almighty ‘think tanks’ is based on outcomes, aka ‘value-based’, healthcare, the pay source is now becoming concerned about the patient. The reality is though, that we are living longer, which equates to extremely costly pathways to health in later life. We must get folks back to a productive life with a purpose beyond existence.  

Seema Verma, administrator of the government’s Centre for Medicare & Medicaid Services (CMS) told American hospitals last year that, “Value-based payment… is the future. So, make no mistake – if your business model is focused merely on increasing volume rather than improving health outcomes, coordinating care and cutting waste, you will not succeed under the new paradigm.”

Verma’s directive is providing a fair warning of the seriousness of the new model. Either focus on quality of care, or else. I find it interesting that this simple message is seen as new and innovative, when the healthcare business historically was designed to treat and never prevent. From a practical position the model was perfect for continuing to expand services, not results. With single illnesses creating an entire industry, why would we ever attempt to create a desired outcome when we could simply wait on the injury or illness to reach a point where healing would take months, rather than weeks?  This obviously would create more revenue for the providers and an increase cost to the pay source (ultimately the consumer et al). The new focus on the patient’s real world setting is refreshing and appropriate. Finally our government standards are in line with the human race – and that of creating a quality of life worth living.

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