United States spent 17.3% of gross domestic product on health care in 2009 (1). If you break it down to the individual level, we can spend $ 7,129 per person annually on health care ... more than any other country in the world (2). With 17 cents for every dollar spent on Americans keeping our country healthy, it's no wonder the government is determined to reform the system. Despite the great attention to health care is getting in the media, we know very little about where that money comes and how it penetrates into the system (and the right ... the way we pay for health care is crazy complex, to say the least) . This system is bent unfortunate result of a series of programs that try to control spending layered on top of one another. What follows is a systematic attempt to peel away those layers, helping you become an informed health care consumers and unquestionable researcher when discussing "Health Care Reform ."
Who is paying the bill?
"Bill payers' fall into three different cells: individuals pay out-of-pocket, private insurance companies, and governments. We can look at these payors in two different ways: 1) How much they pay, and 2) How many people pay for
Most people in America are insured by private insurance companies through their employers, then another by the government. These two sources of payments accounts combined for close to 80% of expenditure. "Out-of-pocket" of taxpayers fall into the uninsured as they are chosen to carry the risk of medical costs alone. When you look at the amount of money each of these groups is being spent on healthcare annually, asks shifts dramatically.
government currently pays for 46% of national health care costs. How is this possible? This will make much more sense when we examine each of the individual payors.
understanding payors
Out-of-pocket
selection of the population chooses to carry the risk of medical expenses instead of buying the insurance plan. This group tends to be younger and healthier than the insured patients and, as such, access to health care significantly less often. Since this group has to pay for all costs, they also tend to be more discriminating in how they approach sustavu.Rezultat that patients (now more appropriately called "consumers") to comparison shop for the tests and elective procedures and wait before than seek medical pomoć.Način payments for this group is simple. Doctors and hospitals charge set fees for their services, a patient pays this amount directly to Doctor / Hospital
Private Insurance
This is where the whole system gets much more complicated. Private insurance is purchased separately or provided by the employer (most people get it through their employer, as we mentioned). When it comes to private insurance, there are two main types: fee for service insurance and managed care insurers. These two groups approach to paying for care is very different.
The fee for the service:
This group seems relatively simple (believe it or not). An employer or an individual purchases a health plan from a private insurance company with a defined set of benefits. This package will also be using what is called refuse (the amount the patient / individual must pay for their health care services before insurance pays anything) . After the deductible amount is met, the health plan pays for services provided during the health care system. Often, they will pay a maximum service fee (say $ 100 for x-ray). The plan would require individuals to pay a copayment (classification costs between the health plan and individual). a typical industry standard is 80/20 Split payments, so that in case $ 100 x-ray, the health plan will pay $ 80, a patient will pay $ 20 ... Do not forget those annoying medical bills specify your insurance did not cover all costs? This is where you come from. Another downside of this model is that health care providers are encouraged and financially and legally bound to carry out more tests and procedures as they are paid additional fees for any of these or held legally responsible for not ordering tests, when things go wrong (called "CYA, or" Cover you ** "drug). If ordering more tests provided you with more protection and more legal fees, would not that somewhat justified? can you tell a deviation from the stimulus
Managed Care:
Now it gets crazy. Managed care insurers to pay for it, and also to "manage" care they pay for the (very clever name, right). Managed care is defined as "a set of techniques used by or on behalf of purchasers used to control health care costs that affect patient care decision making through case-by-case assessment of the appropriateness of care prior to its provisions" (2). Yep, insurers make medical decisions on your behalf (you sound as scary as it does for us?). The original idea was driven by a desire by employers, insurance companies and the public to control rising health care costs. It does not seem to work quite yet. Managed care group or to provide medical care directly or contract with a select group of health care services. These insurers are further divided based on their personal styles of management. You May be familiar with many of these sub-types as you had to choose between you when choosing your insurance.
preferred provider organization (PPO) / Exclusive Provider Organization (EPO) : This is the closet managed care gets the benefit service model with a lot of the same features as a fee for service plan as well as deductibles and copayments. PPO and EPO contract with a set list of services (we are all familiar with these lists) that were agreed upon set (read: discounted) fees for care. Yes, individual doctors have to charge less for their services if they want to see patients with this insurance planova.EPO is less strictly regulated and a list of doctors from the PPO, but are otherwise the same. PPO cost control requires preauthorization for many services, a second opinion for major procedures. All this aside, many consumers believe that the greatest amount of autonomy and flexibility of the PPO's.
health management organization (HMO) : a combined HMO-insurance health care. This model will not have deductibles, but will have copayments. In the HMO, the organization hires doctors to provide care and it builds your hospital or contracts for hospital services in the community. In this model the doctor for insurance providers directly (the staff model HMO). Kaiser Permanente is an example of a large HMO that we heard mentioned often during the recent debate. Since the company was paying the bill also provides care, HMO's hard to emphasize preventive medicine and primary health care (Kaiser, enter "thrive" campaign). Healthier you are, the more money the HMO sprema.HMO emphasis on maintaining healthy patients is commendable because it is the only model for this, however, with a complex, lifelong, or advanced disease, they are encouraged to provide the minimum care necessary to reduce costs. It is with these conditions, we hear the horror stories of inadequate care. That being said, physicians in HMO settings and continue to practice medicine as they feel the need to get the best care for their patients, despite the incentives for cost reduction inherent in the system (given that physicians are often paid in the HMO and have no incentive to order more or fewer tests ).
Government
The U.S. government pays for health care in different ways, depending on which payment. The government, through various applications, provides insurance for people over 65 years of age, persons of any age with permanent kidney failure, some people with disabilities under 65, military, veterans, federal employees, children of low-income families, and most interestingly, prisoners. It also has the same characteristics as the fee for service plans, with deductibles and copayments. As you would imagine, most of these populations are very expensive to cover medically. Although the government only provides 28% of the U.S. population, they are paying for 46% of all covered skrbi.Populacije states are among the sickest and most medically needy in America, which resulted in the disparity between the number of insured individuals and the cost of care.
and most well-known government programs as Medicare and Medicaid. Let's take a look at these individually:
Medicare :
Medicare program currently covers 42.5 million Americans. To qualify for Medicare, you must meet one of the following criteria:
over 65 years of age
permanent kidney failure
meet certain terms of disability
to meet the criteria ... What you get? Medicare comes in 4 parts (part of the new era), some of which are free, some of which you must pay. You've probably heard of various parts over the years thanks to CNN (remember the excitement about the Part D drug benefit during the Bush Administration?), But we'll give you a quick refresher just in case.
Dio (hospital insurance): This part of Medicare is free and covers any inpatient and outpatient hospital patient May need (for a certain number of days, however, with the added bonus of copayments and deductibles. .. Seems to really there is no such thing as a free lunch).
Part B (medical insurance): The part that you need to buy, covers physician services, as well as selected other health services and supplies not covered by Part A. How much does it cost? Part B premium for 2009 range from $ 96 , 40 up to $ 308.30 a month, depending on your household income.
Part C (Managed Care): This part, called Medicare Advantage, a private insurance plan that provides all the coverage specified in Parts A and B, and must cover medically necessary services. Part C replaces Parts & B. All private insurers that want to provide Part C coverage must meet certain criteria set by the government. Your care will also be managed as many HMO plans previously discussed.
Part D (prescription drug plans). Part D covers prescription drugs and cost $ 20 to $ 40 per month for those who chose to enter
Ok, now that the Medicare pay for everything? Hospitals are paid in advance the amount of money on entry or at an outpatient procedure for services to Medicare patients. These forward is based on more than 470 diagnosis related groups (DRGs) and Ambulatory Payment Classification (APC), rather than the actual cost of care (an interesting way to wedge the hospital fee ... especially when the Harvard economist who developed the DRG system do not agree with its use for this purpose). cherry on top of irrational compensation system is that the amount of money assigned to each DRG is the same for each hospital. Totally logical (you can sense our sarcasm?). The figure is based on a formula that takes into account the type of service, type of hospital, and place in a hospital. This may sound logical, but often times the system fails.
Medicaid :
Medicaid is a jointly funded (funded by both federal and state governments), health insurance program for low-income families. The right rules vary from state to state and factors of age, pregnancy, disability, income and resources. Poverty alone does not qualify a person for Medicaid (currently there is no government provided insurance for the poor ... the U.S. despite the fact that almost all first world countries have such a system ... Enter the current discussion of health care), but jeznačajan factor in Medicaid eligibility . Each state is doing its Medicaid program, but must adhere to certain federal guidelines to receive adequate federal funding (May you be familiar with California Medical, Massachusetts MassHealth and Oregon, the Oregon Health Plan because of the recent media coverage). Medicaid payments currently support nearly 60 percent of all nursing home residents, and about 37 percent of all childbirths in the United States.
How are bills paid?
Now to figure out who pays the bill, but we still cover many of these bills are paid. There are two broad divisions solutions for payment and delivery of health care:. Fees for care services and prepaid him
The fee for the service
As mentioned briefly, as they talk about ROM's, the service fee structure, consumers select a provider, to receive welfare (called "services") from the service, and incur the costs (so-called "fees") zaskrb . Deductibles and copayments are also required, as previously discussed. Quite jednostavno.Liječnik is then reimbursed for their services as part of the insurer (ie, private insurance company or government) and partly by the patient, who is responsible for unpaid state insurer (back to unforeseen medical bill, despite their overpriced insurance). Again, the drop in fee for service approach is to encourage medical professionals to provide services (and I mean any and all services that can legally demand or request that must be protected by law), some of which may not be necessary to increase their income and / or a "CYA" (revenues steadily declined as insurance companies continue to lower the amount you pay for health care professionals for their services ).
list
list works the same way you do not charge for the service with one exception: instead of using the "usual, customary and reasonable" amount to compensate health workers, the government set a fee that pays for certain procedures and very usluga.Naknadu low ($ .10 -. 15 on the dollar) and barely covers the actual direct cost of care. Doctors may decide to opt into the plan or not (starting to see why the doctor can not be so excited about this plan?). Would you sign up to be paid 10 cents for every dollar you charge for your work? Try to access compensation insurance next time you go out to eat. We will come bail you out of the Big House, if things go awry. What happens when the insurance system to? You can get a Wal-Mart approach to medicine (high volume, low quality). Not the type of heath care is recommended.
pre-paid
pre-paid
Home Message:
Home Message:
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Reference
1 N. Levey Soaring health care costs raises record. Los Angeles Times. 4th February 2010.
2 J McKenzie, Pinger R, Kotecki J. Introduction to Community Health, 6 Ed. Jones and Bartlett Publishers. 2008th
3 Bodenheimer TS, Grumbach K. Understanding Health Policy. 5th Ed. Lange Medical Books / McGraw-Hill. 2002.
4 Kaiser Family Foundation. "Explaining the Reform of health care: How health care costs vary by region?" Brief # 8030th December 2009.
