Stealing ideas to build a better mousetrap is a good strategy for challenged innovators. Such is the endeavor assumed here – Proposed Health Care Reimbursement Model.
From a midwest insurance consultant:
REMEMBER THE OLD bASE/sUPPLEMENTAL PLANS? I PREDICTED BACK IN THE EARLY HMO DAYS WE WOULD EVENTUALLY RETURN TO BASE/SUPP PLANS WHICH IS ABOUT WHAT YOU HAVE DESIGNED HERE.
EDITOR: YES, EXACTLY. THE ONLY DIFFERENCE IS THAT IN THE OLD INDEMNITY DAYS (1970’S EARLY 80’S) THERE WAS LITTLE OR NO BALANCE BILLING ISSUES.
From a PBM:
Sticking to my very small area of knowledge, I have a couple of comments on the prescription piece. The 50% copay should save a lot of employer expense on prescriptions but could run up the medical. The obvious example would be Type 1 diabetes, where 50% of the cost of insulin and supplies could very possibly be out of the reach of patients and thus could result in dialysis, amputation, transplantation, etc. However, if you start making exceptions based on disease states it becomes difficult to know where to draw the line.
When we look at excluding “Specialty Drugs” we would need to really clarify the definition of specialty drugs. A generally accepted definition is drugs utilized by a very limited number of patients for specific disease states that are associated with a very high cost. That definition works fine when defining a copay tier but may be difficult to defend when someone is denied coverage of a drug.