I will first try to give an overview of nongovernmental programs and then albeit incomplete the federal sponsored programs. After this it will be time to try to give pros and cons of various proposed solutions.
The problem facing America is how to extend affordable health care services to the approximate 70 million Americans who are either underinsured or have no insurance.
It is not clear if the uninsured number includes the “Illegals” who also burden the system. In most states the provider receives no compensation for their care. Therefore the burden is moved to those who pay for care and most heavily onto the uninsured but with some financial resources individual.
Briefly the modalities used by those who have some protection to pay for Health Care break down into the following groups:
Private individual insurance
Private Group Insurance
a) Service Compensation
b) HMOs
c) PPOs
d) POS
Concierge Plans
Federal
a) Medicare
b) Medicaid
c) VA
d) Indian Health Service
e) Military Health Services
f) TRICARE
g) EMTALA
h) Federal Employees Health Benefits Program
Private Individual Insurance plans are very expensive. The individual has no clout with the carrier and often there are strict limitations often in small print on the amount of coverage. Too often this type of protection exposes the individual to economic catastrophe. Many plans are of the Buyer Beware type.
Although many HMO, PPO, POS plans have provision for individual subscribers the premiums are much higher than those in a group plan.
Private Group Insurance Plans vary; all have in common that regardless of the plan group premiums are easier to actuarially determine and the larger the group the more clout it has in determining rates and provisions. Some plans have part of the premium paid for by the sponsor, for others it is completely the responsibility of the insured.
The benefits of the non HMO/PPO plans can vary from an extreme of minimal coverage to no limits. Here the principle of you get no more than you pay for applies.
The HMOs all are of the “gatekeeper” concept. The primary care physician is the key. These plans are of several types;
• The closed panel in which the individual selects his/her physician. All treatment, diagnostic testing, and specialist referrals must flow through the “gatekeeper” and may be restricted to only panel members. The patient has no choice of specialist or hospital. Any service rendered outside the panel is not covered. Most of these plans are “Facility” located. The Original “Rutgers HMO” was of that type and received heavy federal subsidence.
• The other plan was of the restricted panel type. The physicians and hospitals had a “contract” with the HMO sponsor (insurance company). The patient had to select a gatekeeper (primary physician) from the panel and was restricted to use only participating specialists and hospitals or surgical clinics in the panel. No non participating provider except in emergency would be paid by the HMO.
The primary care physician received a per capita per month reimbursement from most of the early HMOs; some were paid on a set for service base. The bigger the doctor’s panel was the more money he made. This led to briefer patient encounters because time and numbers was money.
The PPO plans at a higher premium permits the patient to choose specialist care often without the need for plan pre-approval. There was also freedom of choice of hospitals.
• Like the HMO the patient had to have a designated participating primary physician (the gatekeeper). Some plans had co-pay at this level. To limit ‘excessive” patient usage.
• The patient could use any participating specialist or hospital (Preferred Provider) after an approved referral by the carrier. There were specific co-pay provisions. Many of the participating physicians received a retainer fee based on the number of patients treated not visits.
• The patient could if desired receive a referral to a non participating physician after carrier approval. In those cases the patient would be responsible for the difference in its fee schedule and the physician’s charges.
• Thus the patient had a degree of choice.
The POS plans were more expensive. They are similar to the PPO in that after the patient had chosen his “gatekeeper”, he was free to use any \ specialist who had a fee agreement with the carrier. There would be a higher co pay involved. Referral usually had to be preapproved. In all cases the physician was paid on a fee for service which may have been negotiated beforehand, if not the carrier’s responsibility was limited and the patient would be responsible for the difference.
Various plans differ in the reimbursement to non-participating physicians and facilities. Co pay and deductibles differ in many of the plans. Again there is the matter of the small print in the contract.*
A relative newcomer to the field of Health Care providing is the so called “Concierge Programs. The principle is that the primary physician has opt out of any contracts with insurance carriers and now is free to set his fee based on the value of his service. Patients are given definitive appointments and there are no waits except foe unforeseen circumstances to see the doctor. The visit is adjusted to the needs not to a time limit due to mass appointments. The doctor is reachable 24/7, not an answering machine and a referral to the ER in an emergency. Many provide for house calls. There is usual a retainer fee paid to the physician and his panel will be limited to a serviceable number. This is a modified return with the exception of the retainer fee to the good old days.
Some plans cover everything done in the physician’s office, X-rays, EKGs, Laboratory studies, others limit the coverage.
Some insurance plans while not paying for the retainer will reimburse on their schedules for all other services.
There are several types;
• Fee for Service: The retainer is relatively small and the doctor charges a fee for his service based on time and problem.
• Retainer Service: The retainer charged is much higher but includes every service and visit normal to the Physician’s office including physical exams.
• Hybrid” There is still a retainer although lower and the physician accepts in full any insurance payment.
To continue
*Recent government legislation requiring the “small print” in credit card contracts to be easy to read, has not yet been extended to insurance contracts.
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