Health care in the U.S.A.
Information:
In order for consumers to actively participate in their own health care, a basic understanding of the current health care system, along with proposed reform issues, is critical. Consumers need to consider what specific services they want/need to have unlimited versus limited access to, what they expect from health care providers, the price they are willing to pay for health care packages, and then make their decisions accordingly.
STRENGTHS OF THE SYSTEM
Nearly all Americans benefit in some manner every minute from the sophisticated research, superb technology, varied facilities, and professional expertise of particularly well educated providers found within the United States Health Care System. Premature infants, who often did not survive 10 years ago, now may develop into normal children due to the specialized care available in newborn intensive care units across the nation. Many adults have been able to live longer, happier and more productive lives because of specialized surgical procedures (such as heart bypass, laparoscopic techniques, organ transplants, laser surgery, and so on); bioengineering machinery (such as artificial hearts, pacemakers, insulin pumps and so on); enhanced diagnostic procedures (such as ultrasound, CT scan, MRI, and so on); improved medications (such as various vaccines, chemotherapy, prescription and nonprescription drugs, and so on); and the knowledge, experience, and skills of a wide range of health care providers.
WEAKNESSES OF THE SYSTEM
The overall "costs" of the excellence in the U.S. health care system have been high, both in dollars and in unequal distribution of benefits. In 1991, over $756 billion dollars were spent on health care. The majority of these dollars currently goes toward high technology interventions supporting the last few months of life. Primary prevention and health-promotion activities are continually underfunded and therefore either limited or nonexistent in most areas. The lack of such services in turn tends to enhance the need for even more intervention dollars.
Infant death rate in the United States remains higher than other leading nations of the world. U.S. citizens pay more for their health care than those of any other industrialized nation. Compared to countries that have universal health care access for all citizens (such as Japan, Canada, and Germany), the United States (with only 85% of its population having health care coverage) has higher health care expenditures despite 2 to 7 less visits to providers per person per year. Furthermore, the average life expectancy in the United States is 2 to 5 years less than that in the other countries mentioned.
Over 37 million Americans have no health care insurance coverage and are ineligible for current government assistance or entitlement programs. The majority of these people and families are among the working poor--those holding low-wage jobs that do not offer any type of health benefits.
HEALTH CARE REFORM
The challenge for health care reform in the United States is to change a costly and complex system (accessible only to those with adequate purchasing power and the stamina to negotiate the system), to one that is universally available and insures quality health care services at reasonable costs to the entire population. It is important for consumers to communicate their ideas and concerns regarding health care to elected or appointed policy makers. The current (1993) debate for reform seems to be more in favor of a competitive market of managed care ("managed competition") over the option of a single payer or national health insurance plan.
"Managed Care" is a health care network in which costs are controlled through utilization management. This means that a primary care provider serves as the "coordinator" for access to specialty care. In managed care systems, the patients are unable to directly seek the (more expensive) care of a specialist for those conditions which may be addressed effectively, and much less expensively, by the primary care provider. An example of this would be going to an ENT (ear, nose and throat) specialist for a common ear infection. In the traditional delivery model, where consumers were able to choose any provider and have services covered, this type of inappropriate provider selection commonly occurred and escalated health care costs.
The providers within managed care networks are frequently evaluated by the organizations. The organizations look at appropriate use of resources and various quality indicators, including outcome measures. Physicians and other providers within managed care systems are often salaried as employees or reimbursed on a capitation method (flat fee paid per patient per year); therefore, their individual incomes are not directly influenced by the number of patients seen, tests ordered, or procedures performed. Such reimbursement methods may provide an incentive for the provider to implement a higher standard of care, with enhanced resolutions, as well as more health-promotion activities.
Patients within managed care systems frequently have the options to either choose a primary care provider within the network or pay additional "out-of-pocket" expenses to access a provider of their choice outside the network. HMOs (health maintenance organizations) and PPOs (preferred provider organizations) are both examples of managed care systems.
"Managed Competition" (as initially described by the Jackson Hole Group, September 1991) involves the federal government, physicians and other providers, hospitals, insurers, employers, and individual consumers with specific roles, in the movement towards health care reform goals of increased access and lower costs.
The federal government role includes eliminating discriminatory practices (such as tax code inequities) and unjust competition by changing federal policies that distort the current market. A "National Health Board" would identify a uniform minimal benefit package, certify plans that offer tax-deductible coverage through "accountable health plans" (AHPs), develop standards and guidelines for "health plan purchasing cooperatives" (HPPCs)--more recently termed "Health Alliances"--and establish a national health outcomes database essential for effective competition between AHPs.
Health care providers in a managed competition framework would be encouraged through changes in the tax codes to form collaborative partnerships with insurance companies. Through such agreements, the provider would be reimbursed with a flat fee paid per patient per year. It would therefore be in the provider's best interest to maintain clients at an optimal level of wellness through health promotion activities. This type of reimbursement arrangement with providers serves to hold the provider truly responsible for health outcomes, not merely the delivery of services.
AHPs, certified by the federal government, would offer health services inclusive of the uniform health care package offering tax-deferred coverage to individuals or employers. Such AHPs would be required to report health outcome data specific to providers within their system. The federal government would also require such AHPs to enroll consumers on a community rating basis, eliminating their ability to deny coverage due to pre-existing conditions and income levels.
"Health Alliances" act as the purchasing agent for individuals not linked to employers, the self-employed, or businesses with fewer than a defined number (for example, 5,000) of employees. Annually, the health plan purchasing cooperatives would provide consumers with a list of AHP's (accountable health plans) to choose from accompanied with quality measures and costs related to each plan.
Ultimately the consumer affects the competitive market by having the choice to change plans at the end of each year. Additionally, methods for consumers to voice their dissatisfaction, and have such concerns reviewed, would be established within individual accountable health plans. National health data collection would be required. It would involve a limited number of variables (defined in collaboration with the National Health Board) included in outcome data reports, specific to the providers within a given AHP. Through such data collection, analysis, and publication, consumers can have some measure by which to judge the quality of care delivered relative to the cost of care.
Finally, within today's health care system, a wide range of models exist and are frequently only referred to by acronym. This "alphabet soup" adds to the confusion and frustrations consumers encounter when attempting to "wade through" the health care system. A brief list of commonly used terms or acronyms and their meanings follows:
HMO (health maintenance organization)--A health plan that contracts with providers for prepaid, comprehensive care for its members. Members are required to obtain care from providers within the HMO. Different models for HMOs include the group model, the IPA model, the network model, and the staff model.- Group model--An HMO in which the organization contracts with provider group practices.
- IPA model (individual practice association)--A type of HMO in which the organization contracts for services with a variety of providers from both individual (solo) and group practices.
- Network model--An HMO in which the organization contracts with a provider network providing multi-specialty care at varied locations.
- Staff model--An HMO that directly hires its own providers and pays them on salary, rather than a dynamic scale influenced by the number of patients they see or procedures they perform.
PPO (preferred provider organization)--A health plan that allows members to freely choose providers, but the insurance builds in financial incentives for members to select providers within a specific system or group.
FFS (fee for service)--A traditional system in which the insurer pays for services after they are received, based upon the provider's fee schedule. Consumers have the freedom to seek care without prior approval from any provider, including specialists.
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