Reply to each students discussion post 1-2 paragraphs. Your responses to peers need to be substantive, with constructive suggestions, critique, or insights. You are expected to use in-text citations and list of references to support your posts.
Rasita Lau (students name)
The U.S. has different health insurance plans, such as private insurance through an employer, Obamacare for low income, and Medicare vs. Medicaid. According to Delivery health care in America by Shi ( 2019), the author mentioned about Medicaid that “The Medicare program, also referred to as Title 18 of the Social Security Act, finances medical care for three groups of people: (1) persons 65 years and older, (2) disabled individuals who are entitled to Social Security benefits, and (3) people who have the end-stage renal disease (ESRD— (p. 232) those people who are age over 65 and up, including a disabled person, etc., will be cover by Medicare and Medicaid with no costs or low costs” (p.232)
For people getting health insurance through their work (HMO and PPO), the employer will pay part of the premium, and the workers will pay at least ten percent of it. For HMOs, the workers will spend less money on the monthly premium plan, but they have to use doctors and hospitals in the approval area. For PPOs, employees who purchase this plan can use any medical facilities they want to go to, but the monthly premium is a little high. Shi wrote about a function and how to be reimbursed for health insurance that “with the other two parties being the patient and the provider. The payment function has two main facets: (1) determining the methods and amounts of reimbursement for the delivery of services and (2) the actual payment after services have been rendered (p.246).
The employer’s private health insurance is a large group that will pay most medical expenses. The workers will pay part of the bills that the insurer does not cover. This could be 10 or 20 percent of the medical cost, depending on the agreement of each plan. “Services covered by an insurance plan are referred to as benefits. Each health insurance plan spells out in a contract both the type of medical services it covers and the services it does not cover” (p.233).
Medicare and Medicaid
The U.S. has different plans, such as insurance will be private health insurance that will pay part of the bill, and Medicaid will be a government fund to cover part of the expenses. According to the textbook Delivering health care in America, by Shi, (2019), “Part A, the Hospital Insurance portion of Medicare, is an actual entitlement program. Throughout their working lives, people contribute to Medicare through special payroll taxes; hence, they are entitled to Part A benefits regardless of their income and assets” (p.232). Those people have to have a work history of at least 40 credits to be eligible for Medicare (Shi, 2019).
Medicare Part B
Shi continues that, “Part B, the supplementary medical insurance (SMI) portion of Medicare, is a voluntary program financed partly by general tax revenues and partly by required premium contributions” (p. 234). The third-party of insurance will pay some portion, which patients will pay out of pocket for a co-pay. That could be a large amount of money before the insurer starts to pay the bill. For example, John purchases health insurance from Anthem Blue cross for $200 for a monthly premium. The deduction in that plan state that he has to pay the deduction $7000 before the insurance starts paying the medical bill.
The different methods of different insurance plans, or lack of insurance, will affect the consumer is patients who are willing to pay high premium have more choice of care. Sometimes they do not have to wait to see a specialist to receive a treatment to service for people who are using low-cost health insurance get less chance to access healthcare facilities they want. Sometimes they have to wait for an extended period to get special treatment and service. Another issue of healthcare delivery service is the overcharging of fees from providers, because of physicians, surgeons, etc. that based on incentives. So, the providers can increase the prices when patients receive the service.
Tiffani Gottschalk (students name)
Within the U.S healthcare system there are three main components of health financing. These main components are loosely coordinated and are known as financing, insurance, and payment. On a broader level, financing refers to the process of managing funds that ensures there are enough medical resources available in which all U.S citizens are able to receive healthcare services. On a personal level, financing refers to the actual payment’s individuals must make to receive healthcare services from providers. Currently, there are many types of health insurance plans available and they differ based on what the consumer prefers when it comes to financing and care available. From a basic standpoint, individuals with health insurance are able to have some or all of their healthcare costs paid by an insurance company in exchange for monthly premiums. Payment refers to the process of healthcare providers being paid or reimbursed for the services they provide to their patients.
Unlike many other developed countries, the U.S has a multi-payer system that is financed through more than one entity. These entities include both the public and private sector. “More than one-third of the U.S. population is covered under various public insurance programs” (Shi & Singh, 2019). Public health plans are financed by the government and individuals who have access to these types of health plans will be eligible based on certain qualifying criteria. A few of the public health plans available to qualifying U.S citizens are:
- Medicare: Individuals must be 65 years or older, have one or more “disabilities,” or have a qualifying end-stage renal disease (ESRD).
• Medicaid: Families with children who receive support from the Temporary Assistance for Needy Families (TANF), individuals who receive supplemental security income (SSI), families with income that is equal to or less than 133% of the federal poverty level (FPL).
• Veteran Health Administration: Individuals must have served and receive at least 10% compensation from a service-connected disability.
Private health insurance plans are also available for individuals who do not qualify for public health plans under certain criteria, and these plans can be bought through the federal health insurance marketplace, private marketplace, or private companies. The most commonly known uses of private insurance are employees who gain employer-based healthcare coverage through their jobs. Some examples of private insurance include:
- Group Insurance
• Managed Care Plans
• High-Deductible Health Plans
Different types of healthcare plans have a direct impact on the consumer because it will ultimately lead to how many healthcare services they will attempt to receive or receive. The concept of “moral hazard” shows us that consumers are more likely to be motivated to receive healthcare services if their services are covered by their health insurance. As discussed previously, consumers who lack healthcare insurance are more likely to have poorer health outcomes due to the services they are not receiving.
Currently, the U.S healthcare system has many types of reimbursement methods that physicians receive compensation through for their services delivered. Based on research, reimbursement methods do have an impact on the type of care physicians provide to their patients. Fee-For-Service (FFS) compensates the physicians on the “number of services performed”. Capitation compensates physicians “per patient per time period”. Salary compensates physicians as a fixed payment, “per period of time”. All of these reimbursement methods are known to influence physician behavior in different ways. According to the article, “Physician Payment Methods: A Focus on Quality Cost and Cost Control”, fee-for-service is known to motivate physicians to perform a higher quantity of healthcare services to a higher number of patients. Capitation reimbursement can lead physicians to accept healthier patients and dump out less healthier patients as this would require less work for the physician and still reward them for the amount of patients they provided care to. With salary reimbursement, physicians are more able to tend to their patient needs without the focus on billing services. However, they are likely to see less patients than fee-for-service physicians (Rudmik et al., 2014). Different reimbursement methods can either lead to higher quality of care or decreased quality of care depending on the incentives that are being provided to physicians through different types of compensation.
Rudmik, L., Wranik, D., Rudisill-Michaelsen, C. Physician payment methods: a focus on quality and cost control. BMC. Retrieved from https://journalotohns.biomedcentral.com/articles/10.1186/s40463-014-0034-6#
Shi, L. and Singh, D.A. (2019). Delivering Health Care in America: A Systems Approach. 7th Edition. Sudbury, MA: Jones and Bartlett Publishers.