Health Care System in US - Advantages & Disadvantages PDF

C22 Understand how the Health Care System works in the US, changes, and advantages/disadvantages Be familiar with the spectrum of health plans (table 22.1) available, costs, coverage, and advantages/disadvantages **POS**...

C22 Understand how the Health Care System works in the US, changes, and advantages/disadvantages Be familiar with the spectrum of health plans (table 22.1) available, costs, coverage, and advantages/disadvantages **POS** **HDHP + HSA** **HMO** ---------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ **Choice Level** Lowest **Main Characteristics** Comprehensive medical coverage with deductibles, copayments, and coinsurance. Access to providers in networks and outside the network (with penalty). A gatekeeper. Any type of health plan with a high deductible of at least (in 2018): \$1,350 for a single individual and up to \$3[,]250 for a family. Rollover savings account with maximum contribution of (in 2018): \$3,450 for a single individual or \$6,850 for a family. Employer and employee can  contribute. Comprehensive medical coverage with low copayments. Access to providers only in networks (except for emergencies). A gatekeeper. **Access to Providers** Same as PPO, but required to see primary care physician (PCP) first. Referral from PCP to see a specialist. (PPO+PCP) Depending on the underlying health plan Staff model: facility only. Other models: in networks only, with PCP as a gatekeeper. **Methods of Reimbursing the Providers** PCPs by capitation; specialists by discounted FFS. Depending on the underlying health plan after the high deductible. Staff model: salaries. Other models: capitations. Individual practice association: capitation for PCP, discounted FFS for specialists. **What Is Required of the Patient?** Same as PPO. Encourage participants to make more informed, cost-conscious decisions about their health care. Patient has to open a savings account, pay deductible and other coinsurance, and copays up to a maximum. Copayment only; traditionally, no out-of-network reimbursement except for emergency care. **The Benefits---Levels of Preventive Care** Same as PPO. Preventive care required by law is covered, as in other comprehensive plans (deductible does not apply). Same as PPO with most preventive care, well-being, baby, physical exams, immunizations, extended dental, vision, and prescription plans. **Prevalence** High Growing High Remember the continuum of health plans (figure 22.2) and major medical plans (figure 22.4) - Prior to the passage and implementation of the Affordable Care Act (ACA), health insurance, like all insurance products, was regulated primarily by the states - The ACA, shifted the mandates and requirements to the Federal - Starting in 2014 employer group plans and all individual health coverage had to provide 10 essential benefit to be considered ACA compliant. They are: 1. Ambulatory patient services (outpatient care, no hospital admission) 2. Emergency services 3. Hospitalization 4. Pregnancy, maternity, and newborn care (both before and after birth) 5. Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy) 6. Prescription drugs 7. Rehabilitative and rehabilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care (but not adult dental and vision coverage) (significantly reduced the number of uninsured Americans) Know why protection against disability is important, especially for younger labor force participants and the characteristics of group LTD coverage You should be familiar with the main components of the Affordable Care Act and what some of the controversies are surrounding the Act Be familiar with why health care costs so much in the U.S. and why we have so many uninsured Americans Review the advantages/disadvantages of Accountable Care Organization and how they may improve quality of care and lower costs