Private-pay patients

Pharmacies have third-party patients and private-pay patients. Private-pay patients, sometimes referred to as cash patients, are people who do not have any health insurance coverage or people who have health insurance that does not cover prescription drugs. From the pharmacy s perspective, patients who pay the pharmacy directly for their prescriptions and later are reimbursed by their insurance company often are indistinguishable from private-pay patients. This type of prescription drug insurance, called indemnity insurance, used to be common, but it now has been replaced largely by service benefit plans. Under a service benefit plan, the patient may pay the pharmacy a predetermined portion of the prescription cost, but the pharmacy is reimbursed directly by the third party for most of the prescription cost. 

This shift toward more third-party payment for prescription drugs has had a significant impact on pharmacy management. Pharmacies determine what price they want to charge private-pay patients, but as will be discussed in more detail later in this chapter, third... 

Most third-party contracts state that the reimbursement rate for a prescription is the lower of two prices (1) the price from the reimbursement-rate formula and (2) the usual and customary (U C) pharmacy price. The U C price, also referred to as the cash price, is the price that the pharmacy would charge a private-pay patient for the prescription. 

In 2002-3 there were 158.5 million community PBS prescriptions -132.7 million (83.7%) to concessional patients (pensioners, seniors, repatriation health beneficiaries) and 25.9 million to general patients. In addition, about 42.1 million prescriptions did not attract a subsidy - 26 million below the co-pa)unent threshold and about 16.1 million private prescriptions, that is, prescriptions for drugs not listed on the PBSorRPBS, for which the consumer pays the full cost of the medicine. Thus 79.0% of prescriptions were for items subsidised through the PBS. 

Third parties may be public or private. Private third parties typically are insurance companies, although other private entities sometimes pay for a patient s prescriptions. For example, some pharmaceutical manufacturers provide free or discounted... 

A significant concern in pharmacy is the level of reimbursement specified in these contracts. In 2000, the average third-party reimbursement for a prescription was 15 percent lower than what a patient would pay for the prescription without third-party reimbursement (USDHHS, 2000). This difference may have increased in recent years because third-party payers have continued to decrease their reimbursement rates. There also are substantial differences in reimbursement rates across third-party payers. For example, many state Medicaid programs reimburse at far better rates than private third-party payers. 

The patient s insurance plan will often dictate the referral options. Even if the patient pays out of pocket for the therapist s services, he or she is unlikely to pay privately for medication evaluation and management. Physician charges are usually more expensive than psychotherapy charges, and appointments with physicians— regardless of whether they are psychiatrists or primary care doctors—are usually paid for by the patient s insurance. Thus, a therapist can usually start the referral process by asking whether the patient has previously seen a primary care physician or psychiatrist whose fees are paid by the patient s insurance. If the patient is comfortable with Dr. X, and the therapist is comfortable with Dr. X, the initial referral decision is made. 

Most physicians today are on a professional treadmill. Their employer requires a certain number of patients to be seen per day, regardless of the nature of the patients needs. Even if the physician is in private practice, it takes a certain (often large) number of patients per day just to pay the overhead. On average and by specialty, the lowest paid physicians in the United States are pediatricians, psychiatrists, and family physicians, so there is little room to maneuver more time per patient. Because a patient is probably happy with the pace and generous time allotment for therapy sessions, it is important to prepare him or her for the often chaotic pace of medicine. 

Individual patients who buy private insurance or pay for healfh care out of pockef. 

Unlike NHS prescription supply (see Section 3.3.8), the patient or the patient s representative will pay you for the entire cost of the medication (plus a mark-up cost and dispensing fee charged by the pharmacy to cover their costs). Therefore, non-NHS (private) prescription forms do not need to be sent off to the NHS Business Services Prescription Pricing Division (or equivalent) for reimbursement at the end of each month (except with the private prescribing of Schedule 2 and Schedule 3 controlled drugs see Section 6.3.3). 

The patient may need to pay for the medication, but this will depend on the type of prescription form to be supplied. If the prescription form that will follow is an NHS prescription form, there will be either no charge to the patient for the supply (if the patient is exempt from prescription charges) or the standard prescription charge amount will be levied. If the prescription form that will follow is a private prescription form, this will be charged as for any private prescription form (see Section 5.1). 

In order to completely understand the situation in Spain, it is important to know first how the Spanish health system works. In Spain, there are public and private hospitals (around 795 hospitals see Fig. 2). ° Every Spanish person has the right to free public health care however, if patients prefer, they can go to a private hospital and pay for the health care that they receive. In addition, some... 

Third-party payers Private insurance companies, government agencies, and self-insured business that pay medical providers for services given to a patient. 

The most important economic characteristic of Contractual Psychiatry is that the contractual psychiatrist is a private entrepreneur, paid for his services by his client its most important social characteristic is the avoidance of force and fraud (and the existence of legal penalties for their use). The relationship between contractual psychiatrist and patient is based on contract, freely entered into by both, and, in general, freely terminable by both (except where the therapist relinquishes some of his options in this regard). The contract consists of an exchange of psychiatric services for money. In short, whereas the institutional psychiatrist imposes himself on his patients, who do not pay him, do not want to be his patients, and are not free to reject his help — the contractual psychiatrist offers himself to his patients, who must pay him, must want to be his patients, and are free to reject his help. 

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