Payvider: Health Insurance Payer and Healthcare Provider Combination Explained
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- เผยแพร่เมื่อ 20 เม.ย. 2024
- Payvider: Health Insurance Payer and Healthcare Provider Combination Explained.
A 'Payvider' is an organization that combines a health insurance company that collects premium and bears risk with a provider of healthcare services (e.g. primary care clinics, specialist clinics, hospitals, etc.)
Kaiser is the oldest and most well known payvider with over 12 million members, 40 hospitals and 618 clinics.
A handful of hospital systems have started insurance companies to become payviders... UPMC and Intermountain are two examples.
Health insurance carriers have placed a major emphasis on becoming payviders.
The reason insurance carriers are so interested in becoming payviders is that revenue from their provider services is not subject to the 85% Medical Loss Ratio that was dictated by the Affordable Care Act.
Therefore, insurance carriers essentially use their insurance money to pay themselves as 'providers' to make additional profits... diverting revenue from traditional hospital systems.
UnitedHealth Group has its Optum provider arm.
Aetna has Oakstreet.
Cigna made a $2.5 billion investment in VillageMD
Elevance (Anthem) has Carelon, which just purchased a healthcare navigation service and a 150 clinic physician practice in Florida called Millenium.
Video on Optum: • Optum: The $101 Billio...
Video on Intercompany Eliminations: • Intercompany Eliminati...
Sources:
about.kaiserpermanente.org/wh...
www.upmchealthplan.com/
selecthealth.org/who-we-are/a...
www.beckerspayer.com/payer/el...
www.healthcaredive.com/news/c...
www.fiercehealthcare.com/prov...
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You're so good at explaining complicated topics and have great energy. Thank you so much for these videos, I work in healthcare tech and this is eye opening.
Thank you for watching and for your feedback.
Love your teaching style. Very detailed and on point. Was able to follow the words spoken vs words written on board perfectly. Thank you. Very informative. Love when all of a sudden your video pops up on my TH-cam.
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Excellent intro to Payvider trend - thank you Dr Bricker.
Thank you for watching and for your feedback.
Couple questions - don't commercial plans have MLRs as well, so why do inter company eliminations only affect MA? And in your example, the $6120 you call profit - is that actually profit, or is it just what the payvider gets to keep (and might have to spend on physician care for the bene and thus actually keep less of the $6120 after costs)
Don't forget Humana is rapidly expanding CenterWell Primary Care. Here in Arizona the largest healthcare system, Banner Health recently expanded from MA DSNP only to MA HMO & PPO plans as well. Keep up the great work, Dr. Bricker. Thank you!
Thank you for those additions.
I appreciate your detailed breakdowns, although this is such a sham it feels like justifying a protection racket.
Thank you for your comment.
Dr Bricker is such a beast. Last 90 seconds of this video I’m thinking, “Okay, so hospitals are shifting the profit to themselves? What’s the problem?”
@8:04 “So here’s why it’s a problem…”
Well played, sir. Well played…
Thank you for watching and for your feedback.
Dr. Bricker I so enjoy these videos, thank you! Vertical integration in healthcare is such a hot topic, I'd be curious to learn more about why entities like United/Optum seem to be getting a lot of the VI criticism, but entities like Kaiser Permanente do not receive this level of criticism. Is it because one is an open network, and the other is closed? Other reasons you might think? Thank you!
This is a really good summary
Thank you for watching.
You can Health First (Brevard Co. FL) to that list. They started with this model back in the late 90's.
Thank you for the addition.
Are there additional administrative costs that the provider has and now are the responsibility of the payvidor which decreases the profit so that it’s less than the 50% that you calculate?
Hi Dr. Bricker, Thank you for another great video! At the end you mention hospitals will go to carriers to get more money from commercially insured on self-funded plans. Are you talking about provider contracts and wouldn't fully insured plans also be affected?
Yes, but insurance carriers want fully insured groups to have steady trending higher claims so the insurers can raise premiums and keep the 15% MLR of a larger number.
As a general rule, risk-based compensation arrangements, where providers are more profitable the better the job they do keeping people healthy, catching disease processes early, advising on behavioral health issues, etc. represent significantly better alignment of incentives among payers, providers and patients than fee-for-service compensation arrangements. I would be curious to hear if anyone has a different view on this topic. Thanks!
Thank you for sharing your thoughts.
Do you believe a free market healthcare system would decrease costs, increase innovation, and improve service quality among hospitals and pharmaceutical companies especially if you got rid of things such as certificate of need to allow more local hospitals to compete with one another?
Yes. Thank you for your comment.
this seems like it should be illegal, it seems anti competitive towards small health care providers
Yes. It is legal. Thank you for watching.
@@ahealthcarezmaybe legal bc they paid off corrupt govt to get their way
The audio in a video is more important than the image quality...
Thank you for your feedback.
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Kaiser is terrible. Don’t use them if you can help it.
Thank you for sharing your experience.