In 2009, America spent 17.3% of its gross domestic product on health care (1). If you break this on an individual level, we spend $ 7,129 per person per year on health care ... more than in any other country in the world (2). With 17 cents of every dollar, Americans spend on keeping our country healthy, no wonder the government is set to reform the system. Despite the overwhelming attention that medicine cares about the media, we know very little about where the money comes from or how it penetrates the system (and rightly ... as we pay for health care, it’s insanely difficult to say measure). This confusing system is the unfortunate result of a series of programs that try to control the costs associated with each other. What follows is a systematic attempt to clear these layers, helping you to become an informed consumer of medical care and an irrefutable debater when discussing Health Care Reforms.
Who pays the bill?
“Bill payers” are divided into three different buckets: individuals paying out of pocket, private insurance companies and the government. We can look at these payers in two ways: 1) how much they pay and 2) how many people do they pay?
Most individuals in America are insured by private insurance companies through their employers, followed by a second government. These two sources of payment together account for about 80% of health care financing. Out-of-Pocket payers end up in the uninsured because they decide to bear the risk of medical expenses on their own. When we look at the amount of money each of these groups spends annually on health care, the cake changes dramatically.
Currently, the government pays 46% of national health spending. How is this possible? This will make more sense when we consider each of the payers individually.
Understanding Payers
Wasteful
The selected part of the population prefers to bear the risk of the medical expenses themselves, rather than buying an insurance plan. This group tends to be younger and healthier than the insured patients, and, as such, gets access to medical care much less frequently. Since this group must pay all costs incurred, they also tend to be much more discriminatory in how they access the system. As a result, patients (now more suitable called “consumers”) compare the store for tests and electrical procedures and wait longer before seeking medical help. The method of payment for this group is simple: doctors and hospitals charge a fixed fee for their services, and the patient pays this amount directly to the doctor or hospital.
Private insurance
Here the whole system becomes much more complicated. Private insurance is purchased either individually or by employers (most people get it through their employer, as we stated). When it comes to private insurance, there are two main types: Fee-for-Service insurers and Managed Care insurers. These two groups approach payment for treatment differently.
Service fee:
This group makes it relatively simple (believe it or not). An employer or individual purchases a health insurance plan from a private insurance company with a specific set of benefits. This benefit package will also have what's called deductible (the amount that the patient / individual must pay for their medical services before their insurance pays for anything). After the deductible amount is met, the health plan pays the fee for services provided through the health care system. Often they will pay the maximum fee for the service (say, $ 100 for an x-ray). This plan will require a person to pay. Surcharge (cost sharing between the health plan and the individual). A typical industry standard is a 80/20 split, so in the case of an X-ray of $ 100, the health plan will pay $ 80 and the patient will pay $ 20 ... remember those annoying medical bills that indicate your Insurance didn't cover all the charges? That's where they came from. Another disadvantage of this model is that health care providers are financed both financially and legally required to perform more tests and procedures, since they are paid additional fees for each of them or they are legally responsible for not ordering tests when something goes wrong (the so-called "CYA or“ Cover You & the A ** ”.) If you order more tests, give you more legal protection and get more compensation, could you order something justified? Can we are with azat misalignment of incentives?
Guided care:
Now it is going crazy. The managed treatment insurers pay for the care and also “manage” the care they pay (a very smart name, right). Guided care is defined as “a set of methods used by, or on behalf of, buyers of health care services to manage health care costs, influencing patient care decisions in each case, taking into account the appropriateness of care before it is provided” (2). Yes, insurers make medical decisions on your behalf (does it sound as scary for you as it is for us?). The initial idea was caused by the desire of employers, insurance companies and the public to control the growth of health care costs. It seems, while not working. The managed treatment groups either provide medical care directly or enter into contracts with a selected group of health care providers. These insurers are further subdivided into their own management styles. You may be familiar with many of these subtypes, as you had to choose between when you choose your insurance.
- Preferred Provider Organization (PPO) / Exclusive Provider Organization (EPO) : This cabinet-driven care falls into a Service Charge model with many of the same characteristics as a Service Charge plan, such as deductibles and surcharges. A contract of PPO and EPO with an established list of suppliers (we are all familiar with these lists) so that they have agreed with the established (are discounted) care fees. Yes, individual doctors must pay less for their services if they want to see patients with these insurance plans. The EPO has a smaller and more strictly regulated list of doctors than PPO, but otherwise they are the same. PPO controls costs, requiring prior authorization for many services and second opinions on basic procedures. All this future, many consumers believe that they have the most autonomy and flexibility with PPO.
- Health Management Organization (HMO) : HMO combines insurance with medical service delivery. This model will not have a franchise, but will have surcharges. An HMO organization hires doctors to help and either builds its own hospital or contracts for hospital services in the community. In this model, the doctor works directly with the insurance provider (aka the HMO model). Kaiser Permanente is an example of a very large HMO that we heard during our recent debts. As the bill-paying company also provides assistance, HMO is preventive medicine and primary health care (included in the Kaiser Thrive campaign). The healthier you are, the more money the HMO saves. The emphasis of HMOs on maintaining healthy patients is acceptable because it is the only model for this, however, with complex, lifelong or progressive diseases, they are stimulated to provide the minimum amount of help needed to reduce costs. It is with these conditions that we hear horrible stories about insufficient care. This suggests that doctors in the HMO environment continue to practice medicine, because they consider it necessary for the best care for their patients, despite incentives to reduce the costs of the system (recall that doctors often receive salaries from the HMO and have no incentive to order more or less tests).
Government
The US government pays for health care in various ways, depending on what they pay for. The government, through a number of different programs, provides insurance for people over 65, people of any age with persistent child disability, some people with disabilities under the age of 65, military, military veterans, federal employees, children from low-income families, and, most importantly, prisoners. It also has the same characteristics as the Service Fee plan, with deductibles and surcharges. As you could imagine, most of these populations are very expensive in medicine. Although the government insures only 28% of the American population, they pay 46% of all assistance provided. The population covered by the government is among the most sick and most in need of medical care in America, which leads to this discrepancy between the number of insured persons and the cost of care.
The largest and most well-known government programs are Medicare and Medicaid. Let's consider them separately:
old-age health insurance :
Currently, Medicare covers 42.5 million Americans. To qualify for Medicare, you must meet one of the following criteria:
- Over 65 years
- Permanent renal failure
- Comply with certain disability requirements
So, you meet the criteria ... what do you get? Medicare comes in 4 parts (part AD), some of which are free, and some of which you need to pay. You've probably heard about various parts over the years thanks to CNN (remember the excitement about the benefits of Part D during the Bush administration?) But we will give you a quick review just in case.
- Part A (Hospital Insurance): This part of Medicare is free and covers any inpatient and outpatient hospital care the patient may need (only for a set number of days, however, with the added bonus of surcharges and deductibles ... apparently, there really is no such a thing as a free lunch).
- Part B (Health Insurance): This part you must purchase covers doctors. services and selected other medical services and supplies that are not covered by part A. What is it worth? The Part B Prize for 2009 ranged from $ 96.40 to $ 308.30 per month, depending on your income.
- Part C (Managed Care): This part, called Medicare Advantage, is a private insurance plan that provides all the coverage covered in parts A and B and should cover medical services. Part C replacements Parts A and B. All private insurers who want to cover part C must meet certain criteria set by the government. Your care will also be managed in the same way as the HMO plans discussed earlier.
- Part D (Prescription drug plans): Part D covers prescription drugs and costs between $ 20 and $ 40 per month for those who decide to sign up.
Ok, now how does Medicare pay everything? Hospitals are paid prepaid amounts for each admission or for an outpatient procedure for services provided to Medicare patients. These predefined amounts are based on more than 470 diagnostic groups (DRGs) or Outpatient Payment Classifications (APCs) instead of the actual cost of care provided (an interesting way to adjust hospital expenses ... especially when an economist from Harvard who developed the DRG system, openly disagrees with its use for this purpose). The cherry on top of the irrational cost recovery system is that the amount of money assigned to each DRG is not the same for each hospital. Perfectly logical (can you feel our sarcasm?). This figure is based on a formula that takes into account the type of service, the type of hospital and the location of the hospital. This may sound logical, but often when this system fails.
federal system of care for the poor :
Medicaid is a jointly financed (funded by federal and state agencies) health insurance program for low-income families. Eligibility rules vary from state to state and from factors of age, pregnancy, disability, income and resources. Only poverty does not qualify a person for Medicaid (there is currently no insurance for the American poor provided by the government ... despite the fact that in almost all countries of the first world such a system ... is in current health care debt), but it is significant factor in eligibility of Medicaid. Each state runs its own Medicaid program, but must adhere to certain federal guidelines for obtaining appropriate federal funds (you may be familiar with the California Medical Plan of Maryland, Massachusetts and Massachusetts of Oregon due to their recent media coverage). Medicaid payments currently help about 60 percent of all nursing home residents and about 37 percent of all births in the United States.
How are bills paid?
Now we understand who pays the bill, but we have not yet considered how these bills are paid. There are two main mechanisms of payment and medical care: payment for services and prepayment.
Service fee
As we briefly mentioned when discussing PPO in the structure of a service fee, consumers choose a supplier, receive a service (aka “service”) from a supplier and incur costs (aka “charge”) for care. Franchises and surcharges are also required, as discussed earlier. Pretty simple. The doctor then receives compensation for his services partly from the insurer (for example, a private insurance company or government) and partly from the patient who is responsible for the balance not paid by the insurer (the return of an unforeseen medical bill from the time you are over-insured). Again, the main downfall of the “fee for service” approach is that health workers are encouraged to provide services (and by this we mean any services that they can legally request or should request to protect legally), some of which can be irrelevant to increase your income and / or "CYA" (income that steadily decreases as insurance companies continue to reduce the amount they pay medical workers for their services).
schedule
The schedule of charges operates in the same way as the “Maintenance Fee” with one exception: instead of using the “usual, ordinary and reasonable” amount for reimbursement of medical workers, the state sets fees for specific procedures and services. Reimbursement is very low ($ 10 - $ 0.15) and barely covers the actual direct costs of providing assistance. Doctors may prefer to abandon the plan or not (to understand why the doctor can not be so excited about this plan?). Will you subscribe to pay 10 cents for every dollar you paid for your work? Try an insurance refund approach the next time you go out to eat. We will go beyond the Big House if everything goes awry. What happens when the insurance system does this? You get a Wal-Mart approach to medicine (high volume, low quality). We do not recommend health care.
Prepaid
Prepaid medical care? How is the phone card? Not really - but close. The prepaid system evolved from the desire of the insurance company to share its risk (otherwise called “combined risk”) with health care providers. In fact, they wanted the doctors to have some kind of skin in the game. In a prepaid system, insurers enter into agreements with health care providers to provide agreed services for the provision of medical care to a specific population of consumers at an established (usually discounted) price for remuneration per person for a certain period of time. What does this mean? That means Dr. Bob gets, say, $ 30 a month to take care of Joe Santberg, including his blood and X-rays. If Dr. Bob spends less than for Joe, he makes money. If Joe is sick every month and needs a lot of tests and follow-up visits, Dr. Bob may lose money caring for Joe. The established monthly fee paid to the doctor for patient care is set at the rate of one member per month (PMPM), called " capulated fee. " Поставщик получает установленную плату за каждого зарегистрированного участника независимо от того, использует ли абонент медицинские услуги и независимо от качества предоставляемых услуг (это не очень хорошо в нашей книге). Теоретически, поставщики должны быть более осмотрительными и потенциально предоставлять услуги более экономичным образом, поскольку они несут определенный риск. Однако часто возникает меньше забот, чем требуется в надежде на экономию денег и увеличение прибыли. Кроме того, врачи поощряются к тому, что вишня выбирает более молодых и здоровых пациентов, потому что эти пациенты обычно нуждаются в меньшем уходе (т.е. они дешевле сохранить здоровье). Нам нравится, что врачам рекомендуется держать пациентов здоровыми, но нам нужно беспокоиться о том, каким образом их поощряют к сокращению расходов (как можно меньше?). Опять же, система стимулирования отстает и призывает поставщиков действовать неэтично.
Сообщение о доставке:
Здравоохранение в Соединенных Штатах сегодня является сложным и беспорядочным в лучшем случае. Слои поверх слоев неудачных попыток исправить систему продолжают поощрять неправильное поведение как у пациентов (из страха медицинских счетов), так и у поставщиков (из-за страха перед банкротством). Мы еще не предоставили каждому американскому гражданину медицинскую помощь (что само собой разумеется в большинстве стран Первого Мира ... даже у Кубы это есть!). Мы тратим больше денег на заботу о наших гражданах, чем в любой стране мира, но мы по-прежнему отстаем от национальных показателей здоровья. Мы считаем, что можно с уверенностью сказать, что мы не получаем лучший удар для нашего доллара. Окончательное решение? Хотелось бы, чтобы мы знали. Только время покажет, куда идет система. Наша цель: помочь вам лучше понять систему, существующую сегодня, в надежде на разработку более эффективной, эффективной и всеобъемлющей системы на будущее. Вы с нами?
Recommendations
1. Левий Н. Резкое снижение цен на здравоохранение устанавливает рекорд. Лос-Анджелес Таймс. 4 февраля 2010.
2. McKenzie J, Pinger R, Kotecki J. Введение в здоровье сообщества, 6-е изд. Джонс и Бартлетт. 2008
3. Боденхаймер Т.С., Грумбах К. Понимание политики здравоохранения. 5th ed. Медицинские книги Ланге / Макгроу-Хилл. 2002.
4. Фонд семьи Кайзера. «РАЗРАБОТКА РЕФОРМЫ ЗДРАВООХРАНЕНИЯ: Как меняются расходы на здравоохранение по регионам?» Краткая версия № 8030. Декабрь 2009 года.
