Health Care Costs and Payment Models



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Health Care Costs and Payment Models


2018• Presentation 2 of 6

Learning Objectives

  • Explain the basics of health insurance and coverage
  • Demonstrate the complexity of health care costs and the large variation in out-of-pocket costs based on insurance status
  • Weigh the impact of insurance coverage and out-of-pocket costs with the ability to adhere to treatment recommendations
  • Explore how provider reimbursement models can affect delivery of high value care
  • Encourage physicians not to practice “one size fits all” medicine

Mr. M is a 28-year-old man with severe abdominal pain, ED diagnosis of a ruptured appendix; treated with IV antibiotics for 4 days, followed by surgery

  • Mr. M is a 28-year-old man with severe abdominal pain, ED diagnosis of a ruptured appendix; treated with IV antibiotics for 4 days, followed by surgery
  • Patient: “I grew up in a family without health insurance my whole life, and our policy was basically ‘Give it a couple of weeks’… so I didn't want to call 911 or go to an emergency room.”

An Uninsured Patient’s Perspective

Julian McCullough, comedian

  • Julian McCullough, comedian
  • Recorded at “Told,” a storytelling show in New York City
  • As heard on This American Life (NPR) (#439)
  • “How much? No health insurance, 7 days in the hospital, … appendectomy:”
  • $45,000


An Uninsured Patient’s Perspective1
  • Cost: Dollar amount for a provider to deliver a health care service
  • Charges: The financial amount a health care provider asks for a service
    • Often much higher than cost and reimbursement
    • Only uninsured patients are billed charges
  • Reimbursement: Amount a third party payer (i.e., insurance) negotiates as payment to the provider
  • Price: the amount a patient pays out of pocket for a service
    • Hardest number to estimate, but this matters most to patients


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