So today we had a meeting of our group within the IT department and one of my co-workers asked some questions about how our payment model works. I asked another question related to his questions and lo and behold, at last, I understand how the medical group model of healthcare works.
It’s pretty sad that it’s taken me this long to grok what the company I work for actually does, but then again, the healthcare industry is pretty durn convoluted. Sabs has long asked about how all of this stuff fits together and now I can finally give him a complete … well, relatively complete … answer.
We’ve talked about this a lot and it turns out that he’s right: that Brown & Toland is a medical group just like Alta Bates. This also means that Alta Bates is a lot more than I realized at first. Yes, yes I know, I’ve been a little slow about this whole thing.
Here’s how it works broken down into the simplest terms and following the money:
1. Member signs up for healthcare with one of the plans that has a deal with Brown & Toland Medical Group.
2. Member pays money to healthplan for coverage (terms of care are managed by the healthplan).
3. Healthplan pays Brown & Toland based on number of members who have elected coverage through Brown & Toland (presumably, by selecting a primary doctor who is a B & T doctor).
4. Brown & Toland Medical Group pays the doctors and specialists in the group for the services they provide to patients from the pool of money that BTMG gets from the healthplans.
That’s the very simplest breakdown. So essentially what we do, is facilitate the payment of our providers for their services. There’s other things tacked onto that of course, but the crux of the organization is keeping tabs on cashflow between the healthplans and the doctors so that the doctors don’t have to deal directly with the healthplans in ordered to get paid for their services. All they have to do, is collect the co-pay.
This is why, however, I wasn’t able to see a doctor out-of-group once I was no longer on a PPO plan. It’s not enough that the doctors were all available through the same healthplan network. When you’re using an HMO and you’re in a group model, all billing has to be done through the group — that’s how the doctor offices get paid for the services they provide. So going out-of-group is just as impossible as going out-of-network. Tricky that.
At any rate, I now grok what my company does for a living. Mostly, it collects money to pay its providers, as well as providing support services for those providers and a more limited set of wellness support services for its members.
The funny part is that, since I don’t live in San Francisco proper, and BTMG only operates in the city, I can’t benefit from any of the programs that my employer has available. So all of the information that I post on our websites, does not apply to me. In fact, I’d need to be looking at the web site for the Alta Bates Medical Group instead.