HealthcareDelivery Systems in the United States
HealthcareDelivery Systems in the United States
TheUnited States is among the countries with the most progressive healthpolicies. The government works to fulfill the objectives of HealthyPeople 2020 by increasing accessibility and equity to services. It isalso among the nations with huge budgetary allocations. Obama’sadministration has increased the number of citizens covered byinsurance schemes. Medical covers in the country are instrumental indefining the procedure of care because they have varied components.
Typeof Health Insurance Coverage
TheType of Health Insurance coverage that I currently use is HMO (HealthMaintenance Organization). Under the HMO plan, one is required tochoose a Primary Care Physician (PCP) from a network of localproviders who then refer the member to specialists or hospitals thatare within the network when need be. All the care under this programis coordinated through the PCP. My source of insurance is through myemployer, an organization that I have been working for since twoyears ago when I joined the university.
AHMO plan is a prepaid health plan where the member is required to paya monthly premium. In exchange, the insurance provides all-inclusivehealth care to the member, covering visits to the doctor, hospitalstays, emergencies, therapy, x-rays and laboratory tests. There isusually a minimal co-payment for every service, for instance, $5 fora visit to the doctor, or $25 for emergency room treatment at ahospital. However, the total medical costs incurred are significantlylower and predictable in comparison to fee-for-service insuranceplans.
Themajor limitations faced by holders of HMO come with choosing aprimary care physician and using providers that are not within thenetwork. For those within this plan, all health care services arecoordinated between the member and the designated PCP. This meansthat a patient must get a referral from the PCP to see anotherhealthcare provider.
Inthe case of a severe allergy, for instance, a patient must schedule avisit with the PCP first so as to get a referral to see an in-networkspecialist. The fact that a patient cannot be covered to see aphysician attend a hospital or facility that is outside the networkexcept in severe cases of emergency also presents huge challenges formembers of HMO plans (Medicare.gov).
HavingAnnual Physical Examination under HMO health plan
Physicalexams are often a compulsory requirement for oversea travels,employment, life insurance and participation in various sportingactivities and programs. Due to the fact that HMOs receive a fixedamount of payment for members’ covered medical care, there isalways the motivation to ensure that clients receive basic healthcarefor their problems before they get serious. Typically, physical exambenefits are part of the HMO package. In this sense, HMO providersare very aggressive in the provision of preventive medical careincluding annual physical check-ups.
Justlike in the case of ailments, a person seeking this service mustapproach their PCP to make treatment arrangements. For the kind ofchecks that the PCP can perform, they may carry them out at theiroutlets though more advanced and specialized procedures are referredto the specific specialists that are within the network (Gold, Drayer& Zucker, 2011). When the physical exam has been performed by anin-network provider, this doesn’t attract out of pocket costs forthe members. Also, there will be no out of network coverage forphysical exams since all must be completed by the in-networkproviders (Hap.org).
Procedureto see a specialist (e.g. ophthalmologist, neurologist or orthopedicsurgeon)
Proceduresunder the HMO program must begin with an appointment at the PCP’soffice. Under some circumstances, the primary care physician may be aspecialist in the medical field that the member requires attention.If this is the case, the patient gets treated by their PCP. However,if the specialized services that the patient requires cannot betreated by their PCP, then the professional must source for a doctorwithin the network who can assist the patient. The rationale for thisis that the health plan will not cover for any care provided out ofthe network unless in an emergency.
Inorder to acquire the best referral services, it is crucial tomaintaining a strong relationship with the PCP to ensure thattogether, the client and the physician make the most appropriatedecisions in managing the patient’s health. Once a specialist hasbeen identified, the PCP will then make out referral documents and anappointment organized.
HMOmembers are only required to present membership cards at the pointsof service as opposed to other plans where they are required to fillout claim forms. This is the method of payment that is used at thein-network specialist’s office during the consultation (Hap.org).
Procedurefor Admission to Hospital for a Non-emergency Elective Surgery
Surgeryis one of the services that the HMO health insurance plan covers. Theprocedure begins with a visit to PCP who must give the initialconsultation before making a referral if the services required arebeyond their capability. In the case of the admission of a patientwho requires a non-emergency elective surgery, the PCP must make thenecessary arrangements to refer the client to the appropriatespecialist within the network. As stated earlier, the referralarrangements are made, and the patient may then attend the sessionwith the recommended professional (Hap.org).
However,this may prove to be complicated if the kind of surgery required isnon-medical in nature. An individual who requires a surgicalprocedure for cosmetic reasons shall require a pre-service reviewadministered by a managing identity or a party that oversees theprogram on behalf of the provider. If approved, a surgeon must besourced from the network and arrangements done for the procedure. Asusual, payment is done from the patient’s card alongside theco-payment that the admission attracts. Should the procedure be foundnon-viable for the HMO plan, then the member will be forced to seekassistance elsewhere and make private arrangements for the payment ofthe surgery (Gold, Drayer & Zucker, 2011).
Howdoes Public Health Differ from Personal Health?
Thedistinction between personal and public health is based on the natureof work and perspective of the providers. Private healthpractitioners serve individual patients and owe their greatest dutyto such endeavors every day. A public health practitioner, on theother hand, owes their allegiance to addressing the well-being of thecitizens in a given area. Public health is, therefore, the scienceconcerned with the protection and improvement of the wellness offamilies and communities. They do this by promoting healthylifestyles and conducting research on the most viable methods ofpreventing diseases, injuries, as well as control of contagiousinfections.
Professionalsin public health attempt to prevent health problems from recurring,through the implementation of educational programs, therecommendation of appropriate policies, administration of servicesand conducting research (McKenzie & Pinger, 2014). Public healthcenters its attention on promoting quality, accessibility, and equityin the provision of care. Clearly, this is in contrast to privatehealth, whose practitioners (doctors and nurses), primarily focuseson treating sick or injured patients.
Gold,J., Drayer, D. & Zucker, C. (2011).Reimbursementfor Emergency and Non-Emergency Services Provided by Out-of-NetworkPhysicians: The Issue of Balance Billing. ABAHealth esource.8 (3)
HealthAlliance Plan of Michigan. HMO: Health Maintenance Organization.Retrieved on 1stOctober 2016 from https://www.hap.org/contracts/HMO/HMOContract.pdf
McKenzie,J.F. & Pinger, R.R. (2014). An introduction to community &Public Health.
Medicare.Health Maintenance Organization (HMO) Plan. Retrieved on 1stOctober 2016 fromhttps://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/hmo-plans.html