With ObamaCare now firmly in place, and with the outside chance the Republicans will repeal and replace it, the bottom line is health care delivery as we have known it is gone for good.
One thing is certain: within 2 to 3 years there will be a two tier health care delivery system in place. Tier One will be government plans and traditional plans that rely on a broad delivery platform. Tier Two will be a restricted, private pay plan with capitated arrangements with primary care physicians and a select panel of specialists.
Tier One participants will find it difficult to seek medical care in a timely basis due to shortage of providers and increased number of insureds in this country. To see a primary care physician may take days. Waiting room waits will be hours long, with patient/physician interchange a scant five or ten minutes.
Tier Two participants will enjoy immediate access to health care through a select panel of providers. Providers (other than facilities such as hospitals and out-patient surgical centers) will be paid through capitated rates – insurance will not be in place other than outlier protection. Referrals to specialists will be directed by the PCP/s to a similar panel with a similar financial arrangement.
Stop loss coverage would apply to Tier Two participants who seek and receive care through hospital and out-patient surgical centers. Reimbursement would be Medicare +20%.
How would the cost of Tier Two compare to Tier One plans? On a capitated basis, $100 PEPM or less should cover the PCP’s and selected specialists. Stop loss and funding levels on facilities would be actuarially based on each insured population as would Tier One Plans, but with the underwriting advantage of basing payment tied to a multiple of Medicare rates.
Editor’s Note: RiskManagers.us in partnership with a actuary/consulting firm is in the process of developing a business plan targeting the San Antonio private sector market.