The payer section allows for comparisons among C-section rates, VBAC rates, the percentage of C-section admissions, and average length of hospital stay, by the type of insurance plan. The payer categories are aggregate only and not company-specific.
The health care industry is experiencing enormous change. Part of this movement involves a shift in traditional roles, especially as it relates to the management of health care. Payers are evolving from the traditional approach of financing the delivery of health care to one of influencing the organization of the delivery system. While it is important to remember that patients are not treated by payers, it is increasingly the case that in today's market, payers directly or indirectly influence the delivery of care. This takes the form of quality improvement efforts, re-certification, utilization management, promulgation of physician practice guidelines, development of select physician and hospital networks, financial incentives - the increasing "management" of care. Many payers place an emphasis on educating their participants and providers about the appropriate use of health care services. This is particularly important in the case of C-sections, where information about the cost and quality implications of C-sections and VBACs can make a big difference.
As these newly emerging and evolving health systems work to achieve positive outcomes for those belonging to their health plans in the most cost-efficient manner, it is important to monitor and report on these issues. This section contributes to that process, one which will be continued and sharpened in future reports.
It is important to recognize that efforts to compare payer groups are still in their infancy. These data should be interpreted cautiously. This is just a starting point; useful as a basis for identifying differences among payers, asking why such differences exist, and for further study. Please keep in mind the following limitations:
This report includes aggregate information by region according to the following categories: Blue Cross-related fee-for-service plans, Blue Cross-related Health Maintenance Organizations (HMOs), Commercial fee-for-service plans, Commercial HMOs, Medicaid fee-for-service, Medicaid HMOs and a category called Other. The subscribers or participants in these programs are aggregated according to the region in which the hospital where they were admitted is located.
An HMO provides its subscribers, through a network of selected physicians and hospitals, a basic and supplemental health insurance and treatment package in exchange for a prepaid premium. There are generally no deductibles, small co-payments, and no claims to file. Patient care is managed by a primary care physician, often called a "gatekeeper," who is responsible for monitoring a patient's care and deciding when specialized care or tests are needed.
Blue Cross FFS plans include indemnity fee-for-service Blue Cross subscribers. Due to inter-regional transfers, these data do not refer to a specific Blue Cross plan. This category was not intended to include participants in Blue Cross-related HMO plans. It may include preferred provider and point of service products or options offered by the four Blue Cross plans operating in Pennsylvania.
Blue Cross HMOs include subscribers in those Blue Cross-related plans that are licensed as HMOs with the Pennsylvania Department of Health. It is not intended to include preferred provider and point-of-service products.
Commercial FFS plans include indemnity subscribers to commercial fee-for-service health plans (for example, Aetna, Prudential, Cigna, etc.) Due to inter-regional transfers, these data do not refer to specific commercial health plans. This category was not intended to include participants in commercial insurer-related HMO plans. It may include preferred provider and point-of-service products or options offered by commercial (non Blue Cross-related) plans operating in Pennsylvania.
Commercial HMOs include participants in HMO plans that are licensed as commercial (non Blue Cross) HMOs with the Pennsylvania Department of Health. Due to inter-regional transfers, these data do not refer to specific HMO plans.
Medicaid FFS plans include recipients in the traditional fee-for-service Medicaid program.
Medicaid HMOs include Medicaid recipients who are enrolled in health maintenance organizations that have contracted with the Pennsylvania Department of Public Welfare.
Other includes patients who were covered under Workers' Compensation, government programs other than Medicaid (for example, CHAMPUS), some self-insured employers and health and welfare funds, associations, self-paying patients or patients without insurance.