The rise of the patient portion is bringing into alignment many of the issues facing struggling providers and the consumers who can’t afford to pay them.  This presents new opportunities to get patients and providers working directly together or through more effective intermediaries.

In most cases, transparency and clarity increase trust. In financial markets, intermediation can play a key role in building clarity and trust.  However, in the healthcare industry, increasingly complex intermediation through third-party administrators, insurers and collectors often reduces transparency and trust while increasing cost for both providers and consumers.

Providers, patients, employers, and insurers, use intermediaries to shift costs or liabilities to other participants in the system; when these risk transfers lack transparency, the actual cost of risk becomes more difficult to estimate, so risk premiums are increased in order to cover a wider range of possible outcomes. Decades of adaptation to changes in the health care finance environment have created a web of nearly incomprehensible relationships and dependencies in which neither the providers nor the patients are clear on which bills the insurers will pay.  Many intermediaries have been added to this web without necessarily adding value to the patient-provider relationship while other intermediaries bring value to these relationships.

• Utilization management firms:  Teams of nurses that preauthorize approval. 
• Provider networks:  They contract with doctors and hospitals and then re-market their agreements to payers.
• Specialty vendors:  They manage specific types of care, especially mental health.
• Pharmacy benefit managers:  They contract with pharmacies and manage drug sales

Advocates at the local level have mobilized to address the injustices they see in individuals’ bills and help patients navigate the intermediation. Programs which train patients how to question coverage and negotiate for discounts have succeeded in reducing bills by up to 90%. While these solutions do not necessarily scale to a national level, they provide an insight into the risks and opportunities created by the current system’s set of financial intermediaries.

Examples of current intermediation between providers and patients where they may be opportunities to optimize include insurance companies, the collections industry and hospital branded credit cards.

• Is there another possibility for intermediation that would increase trust? Can intermediaries bring common interests of the stakeholders to the attention of those stakeholders?
• Are there models where insurance does not play the intermediary within healthcare? 
• What can we learn about intermediation or disintermediation from the VA system?
• How does Maryland’s “all payer system” work, paying special attention to how this has impacted the patient portion?
• Where are examples within health care delivery where we see traditional intermediation disappearing and direct patient-provider interactions emerging? Are there models of good intermediaries emerging in these examples?
• Where do effective intermediaries exist?  What is the measure of effectiveness?  What are the other applications of other (housing, economic development) effective intermediaries?

• Credit cards
• Intermediated incentive programs
• Online healthcare interfaces
• Cost containment vendors
• Staff and group model health plan