Both privileged and marginalized payers should reflect on the completeness, difficulty, and straightforwardness of procedures, processes, and payments.
When it comes to procedures that are reimbursed at reduced rates due to their incomplete nature, it is important to consider the reasons behind the failure to complete them. Were the factors patient-related, provider-related, or related to the location? Were there issues with the preparation for the procedures themselves? Furthermore, if the failure to prepare for procedures was deemed patient-related, provider-related, or place-related, were the procedures eventually completed and fully reimbursed at a later time? Did different providers or locations come into play, with better preparations made?
Likewise, for procedures that are reimbursed at higher rates because they are deemed difficult, it is essential to reflect on the factors contributing to the challenges in completing these procedures. Were the difficulties patient-related, provider-related, or related to the location? Did the complexity of the procedures themselves pose obstacles? Additionally, if the difficulties in completing complex procedures were attributed to patients, providers, or places, were the procedures eventually completed within a reasonable timeframe? Did they require the involvement of different providers or a change in location with improved preparedness?
Moving on, payers should consider the challenges involved in payment processes even in the case of completed easy and simple procedures. Providers and institutions often struggle to maintain fair market values, and payers must assess if they are adequately compensating. If not, what are the reasons for their failure to do so? On the other hand, if providers and institutions are requesting excessive amounts, payers must understand why they perceive it as excessive. Is it because payers are aware that they will never provide sufficient compensation? If payers are not directly paying providers enough, what is the source of funds that institutions use to support their undervalued providers and keep them financially stable? Are these direct institutional payments intended for the providers’ time and immediate availability when no reimbursable activities occur? Or are they meant to supplement poorly reimbursed activities provided by payers directly to providers? Are payers attempting to pressure providers into redefining their fair market values? Or are privileged payers shifting the burden onto marginalized payers and institutions? Ultimately, who will be responsible for these expenses when it comes to balancing their financial books and remaining afloat? Customers? Governments? Taxpayers?
Rather than working independently, focusing solely on their submitted charge amounts and corresponding allowed amounts within their own isolated environments, privileged payers, marginalized payers, providers, and institutions should come together and engage in collaborative discussions. They should strive to reach a consensus that is agreeable to all parties involved. This would ensure that factors determining reimbursement for difficult and/or incomplete procedures primarily consider patient-related aspects, if not exclusively. Additionally, it would prevent complex processes in direct fair market value payments to providers and institutions from leading to indirect payments borne by society as a whole.
Deepak Gupta is an anesthesiologist.