4P in Digital Health: Prospectus Filed for Innovative Healthcare Ecosystem Platform
Mar 03, 2022 09:37
CST Updated
09:37
What is “4P”?
There are various interpretations of the “4P” concept in healthcare, which differ from one another. One such interpretation comprises four key elements: Patient, Physician, Provider (i.e., Healthcare Provider), and Payer. Since physicians fall under the category of healthcare providers, the traditional healthcare ecosystem consists of three main stakeholders: Patients, Providers, and Payers.
Patients:
In the U.S. healthcare system:
1. Patients can choose medical insurance plans;
2. Citizens over the age of 65 are eligible for medical insurance;
3. Residents below specific poverty thresholds are eligible for medical assistance programs;
4. Annual registration is required, except under special circumstances;
5. 15% of the population still lacks health insurance coverage
What should patients do when they fall ill? There are two scenarios—
Uninsured: Visit the emergency room or participate in Medicaid
Insured:
1. Choose a Family Doctor
2. Family Doctors Become Care Managers
3. Family physicians must refer patients to hospitals
4. Track payment status and cover partial costs
Healthcare Providers (Providers), which refers not only to family physicians but also to any individual or institution capable of providing professional services to patients, all of whom are termed “Providers.” This category includes the following entities:
1. Physician
2. Hospital
3. Laboratory
4. Pharmacy
5. Pharmaceutical Companies
6. Home Care and Other Professional Nursing Services
What are the primary responsibilities of providers?
1. Family Doctor: One-on-One Medical and Nursing Services
2. Medical Experts: Professional Services
3. Hospitals: Inpatient and Emergency Care
4. Pharmacy: Drug Prescription
5. Pharmaceutical Companies: Produce Medicines as Scheduled
Payers: The payers include the following entities—
1. Medical insurance or medical assistance policies implemented by the national government and local state governments
2. Health Maintenance Organization (HMO) Plan
3. Private Insurance Companies
4. Patient Individuals
What Do Payers Do?
1. Paying for Medical Services
2. Establish Reasonable Fee Standards
3. Negotiate with Providers on price and service quality
4. Manage healthcare affairs in areas such as prior authorization, referrals, case management, and preventive care
In addition, the federal government is by far the largest payer, with its Medicare program primarily benefiting individuals aged 65 and older. Medicare spending is estimated to have reached $792 billion in 2015. During the same period, Medicaid expenditures are projected to reach $670 billion. The number of newly enrolled beneficiaries in U.S. health insurance programs is expected to increase year by year:
There are various interpretations of the “4P” concept in healthcare, which differ from one another. One such interpretation comprises four key elements: Patient, Physician, Provider (i.e., Healthcare Provider), and Payer. Since physicians fall under the category of healthcare providers, the traditional healthcare ecosystem consists of three main stakeholders: Patients, Providers, and Payers.
Patients:
In the U.S. healthcare system:
1. Patients can choose medical insurance plans;
2. Citizens over the age of 65 are eligible for medical insurance;
3. Residents below specific poverty thresholds are eligible for medical assistance programs;
4. Annual registration is required, except under special circumstances;
5. 15% of the population still lacks health insurance coverage
What should patients do when they fall ill? There are two scenarios—
Uninsured: Visit the emergency room or participate in Medicaid
Insured:
1. Choose a Family Doctor
2. Family Doctors Become Care Managers
3. Family physicians must refer patients to hospitals
4. Track payment status and cover partial costs
Healthcare Providers (Providers), which refers not only to family physicians but also to any individual or institution capable of providing professional services to patients, all of whom are termed “Providers.” This category includes the following entities:
1. Physician
2. Hospital
3. Laboratory
4. Pharmacy
5. Pharmaceutical Companies
6. Home Care and Other Professional Nursing Services
What are the primary responsibilities of providers?
1. Family Doctor: One-on-One Medical and Nursing Services
2. Medical Experts: Professional Services
3. Hospitals: Inpatient and Emergency Care
4. Pharmacy: Drug Prescription
5. Pharmaceutical Companies: Produce Medicines as Scheduled
Payers: The payers include the following entities—
1. Medical insurance or medical assistance policies implemented by the national government and local state governments
2. Health Maintenance Organization (HMO) Plan
3. Private Insurance Companies
4. Patient Individuals
What Do Payers Do?
1. Paying for Medical Services
2. Establish Reasonable Fee Standards
3. Negotiate with Providers on price and service quality
4. Manage healthcare affairs in areas such as prior authorization, referrals, case management, and preventive care
Among the reasons why insurance companies are willing to cover medical expenses are:
1. Insured individuals will generally remain healthy
2. Disease risks are identified and controlled at an early stage
3. Minimize complications from various diseases as much as possible
This third-party insurance payment model is a key mechanism for checks and balances in the U.S. healthcare system, introducing competition through privatization, as specifically demonstrated by:
1. Healthcare providers compete to capture payer resources
2. Payers Compete for Patient Resources
3. Multiple Payers Exist at Each Market Level
4. Each tier of the market also has multiple healthcare service providers
5. Engage in fierce competition over pricing and the quality of medical services
In addition, the federal government is by far the largest payer, with its Medicare program primarily benefiting individuals aged 65 and older. Medicare spending is estimated to have reached $792 billion in 2015. During the same period, Medicaid expenditures are projected to reach $670 billion. The number of newly enrolled beneficiaries in U.S. health insurance programs is expected to increase year by year:
