US Healthcare System Overview

US Healthcare System

• The US healthcare system is characterized by high spending but not necessarily higher life expectancy or quality of healthcare compared to other wealthy countries.
• The US spends roughly twice as much per person on healthcare compared to other wealthy countries.
• The US healthcare system is fragmented, with many different ways to get insurance, which can be confusing and time-consuming.
• The US has the highest healthcare standards, with professional and facility licensures and certifications, as well as advanced technology available.
• The US healthcare system is inflationary, wasteful, and unfair.
• There are significant socioeconomic and racial disparities in healthcare outcomes in the US.
• The US healthcare system is characterized by excess care (waste) for some and too little care for others, with factors like insurance coverage playing a large role.
• The US healthcare system is also subject to maldistribution, where high socioeconomic patients have access to better healthcare, while lower socioeconomic patients face reduced access and higher costs.

Excess Care

• Out-of-network coverage is a major contributing factor to excess care in the US.
• Managed Care Organizations (MCOs) are designed to control healthcare costs by managing provider networks and patient access.
• Health Maintenance Organizations (HMOs) are a type of MCO that generally only cover care received within their network, with providers bearing some financial risk.
• Preferred Provider Organizations (PPOs) are another type of MCO that allows individuals to see any provider but provides incentives for using in-network providers.

PBM Services

• Pharmacy Benefit Managers (PBMs) are companies that manage prescription drug benefits for health plans.
• PBMs negotiate discounts and rebates with pharmaceutical manufacturers, which can be based on factors like formulary status, prescribing volume, and market share.
• PBMs also manage claims adjudication, formulary status, prior authorization, and therapeutic alternatives.
• PBMs often utilize tiered copayment systems that encourage the use of preferred drugs over more expensive options. These tiers can include generic drugs, preferred brands, non-preferred brands, lifestyle drugs, and non-formulary drugs.

Formularies

• Formularies are lists of approved drugs that are covered by a health plan.
• Formularies can be open, closed, or incented.
• Open formularies cover all drugs. 
• Closed formularies only cover drugs on the list.  
• Incented formularies offer financial incentives to use preferred drugs, often through tiered copayment systems. 
• Prior authorization programs require physicians to request approval from the PBM before certain drugs are covered.
• Step-therapy programs require less expensive first-line drugs to be proven ineffective before more expensive second-line drugs are covered.
• Therapeutic alternative programs allow pharmacists to dispense therapeutically equivalent drugs instead of the prescribed drug. 
• Therapeutic interchange (or conversion) programs involve contacting the prescribing physician and patient for approval before a therapeutic alternative is dispensed.

Explore the complexities of the US healthcare system, which, despite high spending, shows disparities in outcomes and quality compared to other wealthy nations. This quiz covers various aspects, including fragmentation, wastefulness, and socioeconomic inequalities affecting healthcare access and quality.