Who’s Who in Healthcare: A Guide to Major NC Stakeholders

Who’s Who in Healthcare: A Guide to Major NC Stakeholders

Healthcare is complicated, often ridiculously so. This is partly because the healthcare system in the U.S. was never planned or designed. It just sort of evolved over time. It’s also because there are a lot of different players involved. In this article, we’ll introduce you to three major healthcare stakeholders: who they are, what they care about and how they impact you.

Providers (Health Systems, Hospitals and Medical Groups)

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Healthcare providers, well, provide healthcare. Provider organizations include health systems, hospitals, clinics, and physician groups. Health systems typically have a lot of power. This power has been amplified in recent years because of a trend of mergers and acquisitions (M&A). Basically, this M&A trend means that health systems have been joining forces and buying up private physician practices to make mammoth organizations with huge market shares.

Health systems usually argue that growing larger through M&A allows them to provide better, seamlessly-coordinated care. Other stakeholders argue that the main driver for M&A is to allow health systems to demand higher prices from insurance companies for providing that care.

Major health systems in North Carolina include Atrium Health (which recently merged with Wake Forest Baptist Health), Novant Health, UNC Health, and Duke Health.

North Carolina has seen some pushback against this trend of health system M&A, however. In 2018, 88 physicians broke away from Atrium Health to form Tryon Medical Partners, an independent medical group. In 2019, 42 primary care doctors followed suit, leaving Novant Health to join a different medical group. Medical groups are composed of physicians who join together into one organization. Because they don’t have to pay for the high overhead costs of running a hospital, medical groups argue they can provide more cost-effective care than health systems can.

Producers (Pharmaceutical and Medical Device Companies)

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Pharmaceutical companies (or “pharma”, for short) and medical device companies manufacture the prescription drugs and other products that providers use to treat patients. Unfortunately, these companies sometimes charge a lot of money for their products.

That’s because, like any company, pharma and medical device companies want to make a profit. Plus, without them, we wouldn’t have anyone creating the products that we need to keep people healthy. Still, high drug prices in particular have been the cause of patient outrage and congressional scrutiny in recent years. With the focus on finding a vaccine for COVID-19, pharma has been getting less bad press recently. However, that tension will likely flare up again in future.

NC has an impressive pharmaceutical industry presence, especially in the Triangle. Major pharma employers include Pfizer, Grifols and GSK.

Payers (Private Insurance, Medicare and Medicaid)

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These guys hold the purse strings. Unless you are paying for all your healthcare out of pocket, your health payer controls what type of care you can receive and who you get it from.

Payers want to keep everyone in their insurance pool as healthy as possible while keeping healthcare costs down. To do this, payers decide which treatments they will cover and which they won’t. They might also put in place some requirements for coverage, such as proving that you have tried a less expensive treatment before they pay for a more expensive one.

Insurers, understandably, don’t have an easy relationship with the other healthcare stakeholders. Healthcare providers and healthcare insurers often struggle with one another over how much the insurers will pay the providers. Insurers and pharmaceutical companies go back and forth over which drugs will be covered for which patients. Insurers and patients struggle over how much patients should pay out of pocket, versus how much insurance will cover outright.

In North Carolina, 46.9% of people have employer-sponsored health insurance. Most of those employer-sponsored health plans in NC are run by BlueCross BlueShield of North Carolina. Other NC residents also have health insurance through Medicare (14.8%) or Medicaid (14.9%, including children on CHIP). North Carolina has lower than average Medicaid enrollment in part because NC is one of the states that still has not expanded Medicaid eligibility.

Patients: The Fourth “P” of Healthcare Stakeholders

Of course, central to this entire health system are you and me, the patients. In many ways, patients have very little power in our current system. However, there is still one major lever we have to affect change within what we pay and how much: voting. New laws and regulations create the rules that all the major healthcare stakeholders have to follow. So why not cast your vote by Nov. 3, to voice your support for your preferred healthcare policy?

And while you’re at it, catch up on our rundown of the 2020 election!

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