How does the health care system work in the USA?

Question

What are the payment systems like for hospitals and doctors?What are HMO's and PPO's?Do people have to pay out of their own pockets to see a doctor?

Many thanks to all the people who answered.I really appreciate all the detailed and insightful answers.However i am still confused about the the payment system for physicians in all these systems.

Thanks!!!!

Answer 1

Complicated Question! I will try to keep it VERY SIMPLE and VERY SHORT.

Hospitals get paid from 3 sources...
- the patient directly
- the government
- insurance companies

They are paid based on the acquity of the patient and paid by procedure.

Doctors can work for the hospital directly, work for a "group" or work for themselves. Groups are companies that employ a lot of doctors. The hospital pays the group and the group pays the docs... or the hospital can pay the doc directly if they are salaried. Also, docs can work for the government and get paid differently. Again, very complicated when you talk about physician pay.

HMOs and PPOs are managed health plans that incorporate everything I just talked about. They seek doctors within their "group" and reimburse based on aquity. However, sometimes (most of the time) they can screw patients... Why? Cuz they are FOR PROFIT ORGANIZATIONS.

Dont get me started on the prescription part of all this.

Places like England have "universal healthcare" systems which means everyone can see a doc. However, the wait times are very long (months) and critics state that acute patients are often disadvantaged... especially those with mental illness or depression.

Regards,
Ryan

Answer 2

Health care is a market driven enterprise in the USA as are all facets of American business. Suppy and demand on care regulates the prices.

However, since the advent of Medicare in the 1960s such a thing as a "customary charge" has evolved. This is what doctors can charge Medicare for a procedure. Medicare usually pays 80% of this charge.

That doesn't mean that there is not a great deal of out-of-pocket charges. Any non-elective surgery is out-of-pocket.

Health Maintenance Organizations (HMOs) evolved in the 1980s and have become a dominant player in the US market with major products from Aetna and BlueCross. In an HMO the Primary Care Physician is the traffic cop. They get a monthly captitation to direct the health services of each patient signed up under their care. Specialty physicians require referrals and other services are "capped". The HMO will only pay a certain number for service, if you are a provider and you accept that number you are in the "network".

Preferred Provider Organizations allow the patient only to visit those doctors and specialists in the PPO. Usually, this insurance is slightly more expensive but there are no co-payments with a PPO. Costs are regulated and there is usually no out-of-pocket expense for the patient.

Make any sense?

Answer 3

Not very well. HMOs are Health Maintenance Organizations where there is no choice of provider and PPOs are Preferred Provider Organizations where there is a choice. Many plans have a deductable where a patient has to pay up to a certain amount before the insurance company will begin paying. Also, there is usually a co-pay, which is a payment made by the patient for each appointment.

Answer 4

Yes, we do have to pay. Even with our insurance, we still have to make a copayment.
HMO- health managed organization. Usually consists of doctors who participate in this program and you have to pick your doctor and get permission or referral from your doctor to see another doctor. (Cheaper than other forms but not as good).
PPO- Much the same except costs more and you can choose your own doctor.

All insurance companies require a deductible before you go to hospital, see a physician, or get medications.

This is also true of people who turn 65 and go on Medicare. They have to pay for Medicare out of their social security check, unless they are considered in the poverty level and then they can request help of Human Services. (which may take a long time to assess). They also can opt to purchase a private insurance plan to go with Medicare or simply choose a prescription drug program. Either way, it costs. Hurts the poor, but the rich it helps. This is true, honestly.
I am just thankful that they still have Medicare which is a shaky subject right now in USA. The government is warning that in the next 20 years or so, there may be no money for Medicare.

Hope I helped answer your questions.

Answer 5

OOOOHHHH!! Such intelligent politically leftist answers!! i.e.: "it don't" "bush runs it" and "you have to be rich to get sick".

These are the people who like sitting in the various DMV (Division of Motor Vehicles) waiting rooms and wish their healthcare was administered the same way!! After all everyone knows that Gov’t bureaucracy is the most efficient, and they always hire the most competent people!!

In the US, if you go to an emergency room, by law, they have to treat you. Therefore all of the deadbeats go there for colds and the flu making it impossible for people with real emergencies to be seen.

A HMO is a "Health Management Organization". The first was started by Henry Kaiser in WW2 to provide healthcare as a benefit to his workers since he wasn't allowed to raise their pay during the war. (OH MY GOD!! A capitalist that cares about his employees!!) (Also sorry about using the word God if I offended anyone, it's just a turn of phrase) An HMO is a Medical Co-Op. You pay a basic fee and get health care from Doctors employed by the HMO. It's like Socialized medicine, but you have the option of belonging and you don't have to subsidize the health care of deadbeats.

PPO's are regular health insurance in which you pay a fee, usually deducted from your salary. You may choose the plan you like and which services are included as part of the plan. These are the most flexible. You usually (not always) have the choice of physicians, and can visit specialists outside of the plan with a recommendation from your primary care physician. You usually have some type of co-pay for office visits ($5-$25) and a co-pay for prescriptions ($5-$25). Some plans have deductibles for doctors outside of the plans and a yearly limit. For an individual it may be $250, a family it may be $1000. Once the deductible has been met you do not have to pay anything until the next year. Like Auto insurance the deductible is higher the cheaper your monthly payment is.

For those leftists out there who complain about the cost of US health care, maybe they should support Tort reform so Doctors don't have to pay $100-$200k a year in Malpractice insurance. It would also lower costs by reducing the number of tests they schedule as CYA tests.
One of the American Left's sweet hearts, 2004 Democrat VP candidate, John Edwards, made his millions by suing Obstetricians for malpractice in Cerebal Palsy cases. Even though it has been proven that there is no link between delivery issues and CP. Now most Obstetricians deliver caesarian section because of Sharks (I apologize to sharks) like Mr. Edwards. It is more dangerous to the mother but they can't be sued for not delivering the baby soon enough.

Also another way to make medical care in the US cheaper is to allow more med school students. The US Gov't and the AMA (American Medical Assoc.) have a deal to limit the number of Doctors Graduated every year. Therefore there is an artificial shortage. Too bad there isn't a limit on lawyers.

Answer 6

Yes. you have to pay out of your own pocket. HMO & PPO are forms of medical insurance. You give a company a predetermined amount of money in a given periiod of time and they tell you what doctors you can visit for a reduced cost to you.

Answer 7

The wellness CARE device will stay precisely because it quite is...the only replace, ought to alter take place, is to the scientific wellness insurance device. The scientific wellness insurance industry could have some opposition and a few new policies. all the different BS you pay attention on suited wing radio and FOX 'information' is strictly that...BS. in case you could mount a controversy against a low value and incredibly attainable 'public decision' non-income insurance business enterprise, permit's pay attention it. yet to rail against a central authority take over of the wellness CARE device is a pink herring if there ever became one. no one has ever stated this way of ingredient, and for the scientific wellness insurance industry to attempt to cajole those that such an theory is even plausible is a fraud, a lie and fully is cheating.

Answer 8

hmo: usually employer aids employee in payment of premiums to receive benefits in a pre-chosen network (think of a spider web). ppo: same thing but the employee will pay higher premiums in exchange for the choice to see whom they want to both inside and outside the network (web). Lots of people pay out of their pockets to see a doctor or other health provider. This includes homeopathic healers, shamins, naturopath doctors and others.

Answer 9

Well if your employer pays you enough they will also usually pay your healthcare...if you are a normal average person with a job...you pretty much get screwed by either ridiculous medical costs or a ridiculous medical insurance plan...Basically the people that can hardly afford healthcare are the ones who have to pay the most and get the shittiest coverage.

Answer 10

the health care system sucks unless your rich enough to get sick i don't suggest it