Write an essay of 1,000-1,250 words that examines the similarities and differences between the various health care delivery systems. Be sure to also include:
1.A definition or description of the various types of delivery systems.
2.The goals or philosophies of the various delivery systems.
3.Your own mission or philosophy statement. Explain your statement and why it was chosen.
Provide appropriate and scholarly sources for your paper. Remember that Wikipedia is not considered a scholarly source.
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Health Delivery Systems
The available health delivery systems include fee-for-service, managed care, Preferred Plan Organization (PPO), Exclusive Provider Organization (EPO), Point of Service (POS) and Health Maintenance Organizations (HMO). All this systems offer specific services to their members. They have benefits and limitation and choice of a plan should be based on knowledge of the available system to enable a client to choose the most suitable for his need. This paper provides a summary of the available systems.
Under this system, the doctors and hospitals get paid for each service they provide (Ferrenc, 2014). There are two main approaches to FFS; fee for service (FFS) plans (non-PPO) and fee for service (FFS) Plans with a Preferred Provider Organization (PPO).
Fee for service (FFS) plans (non-PPO)
It is a traditional method of insurance where the health plan uses either the indemnity or the reimbursement method. In indemnity plan, the medical provider is paid directly by the health plan (Ferrenc, 2014). The reimbursement plan involves the patient paying the medical providers then filing an insurance claim for each covered medical expense where the insurance will then reimburse you. However, the insurer only pays the medical expenses termed as ‘reasonable and customary’ which is determined by what other practitioners in the area charge for similar services. This process favors the doctors and not the patient since a doctor can charge more than the rest resulting to the plan paying what is considered reasonable and leaving the rest to be paid by the patient. Although traditionally, preventive care was not covered under FFS, rising evidence of their importance has made some insurers offer them. The insurance company does not have to give you permission to see a specialist or decide whether it was a necessary visit.
Fee for service plan with a preferred provider organization
This plan allows the patient to go to medical providers who have reduced their charges to the plan (Ferrenc, 2014). The result is less money out of pocket paid by the patient. There is also no paperwork required or claimed to be filed. The disadvantage is despite going to a PPO hospital, it is not a guarantee that you will get PPO benefits for all the services you will receive in that hospital. An example is services like laboratory work provided by independent practitioners within the hospital may not be covered by the plan. Another disadvantage is despite most of the networks being wide; they may not have all the doctors and hospitals you want. The major advantage is it saves money.
It is an approach that optimizes patient care by putting scarce resources to best use (Kongstvedt, 2013). . It developed as a result of economic and social needs that were not met. It is a dynamic, highly regionalized phenomena determined by territorial demands. It tries to balance cost efficiency with quality care. Although there are many kinds of managed care organization, they have common characteristics. The similarities include; supervision of the financing of medical care provide to members, are concerned with cost effectiveness and management of the delivery system for their members including who provide the care and where it is provided. They lower the prices by buying services in bulk, limiting choice which means that the doctors patients can see are listed and the doctors have a list of the medicine they can offer. Limited choice is therefore the main disadvantage of managed care. They include EPO, PPO, POS and HMO
Differences between FFS and managed care
Method of payment
In FFS, the patient is expected to pay the yearly deductible which is around $200-$500. During visits to the physician, he will pay the bill upfront then late file a claim to receive reimbursement which is usually 80% of the amount. On the other hand, in managed care, the physician is responsible for the paper work and you will be expected to make a co-payment of $5, $10 or $15.
Consultation of specialist
Although in FFS some specialists prefer recommendation from a general practitioner when you see them, you have the ability to see any physician any time. Under managed care, a primary care physician has to determine the necessity of seeing a specialist before any referral is made. However, in some plans you can go out of network but the cost will be higher.
Quality of physicians
Under FFS, the qualification levels of doctors vary and since you can see any doctor, you are also responsible in making sure that you get the most appropriate care from a qualified physician. In managed care plan, when doctors are invited to join the network, the plan takes some verification measure to determine whether they are qualified. It is estimated that about 81% of the physicians in the network are board certified.
Preferred provider organization (PPO)
They have lower prices than managed care with health care providers and this gives their clients an incentive to stay within the network (North Dakota Public Employees Retirement System., & BlueCross BlueShield of North Dakota, 2000). It is similar to FFS when seeking care outside the network since you will be requires paying the whole amount upfront and then later filing a claim from which you will be reimbursed 80%. However, when care is in-network, it is similar to managed care as you will only be required to pay a small amount as co-payment. The difference with managed care is you can go to a specialist without waiting for referral and still be covered. The advantages of staying in-network include less out of pocket pay and paperwork.
Exclusive provider organization (EPO)
Under this plan, choosing an out of network care means paying the entire cost yourself (North Dakota Public Employees Retirement System., & BlueCross BlueShield of North Dakota, 2000). They are similar to PPO in limiting choice.
Point of service (POS)
They are similar to PPOs but require the client to choose a Primary Care Physician from their list (New York (State)., New York Health Plan Association., & New York State Conference of Blue Cross and Blue Shield Plans, 1996).They offer the choice to go out of network like PPOs while giving some cover. However, referrals need to go through your PCP if the process is to be easier. Referring yourself means more out of pocket money and more hassles. A deductible may also be paid if the care is from out of network. When the out of network referral is from your PCP, the plan will cover most of the cost. They may offer more preventive care than PPOs and even include health improvement programs like smoking cessation.
Health maintenance organizations (HMO)
They are similar to PPOs but are less flexible and cheaper (United States, 1996). They are also preferential to members of group plans than individuals. Referral from your PCP to see a specialist and staying in network provides low co-payment or no co-payment, minimum paperwork and low premiums. It requires a patient to seek clearance before going to an emergency room as long as you are able to pick a phone. It might consist of a central medical offices or a network of individual practices. They are thought to offer the best preventive and health improvement services. If you go out of network you are supposed to pay the entire cost.
As a potential client, my goal would be to get the most out of the available systems while paying the least. Cost of health care is not cheap and finding a system that offers quality for minimum cost is important.
Ferenc, D. P. (2014). Understanding hospital billing and coding. St. Louis, Mo: Elsevier.
Kongstvedt, P. R. (2013). Essentials of managed health care. Burlington, MA: Jones and
New York (State)., New York Health Plan Association., & New York State Conference of
Blue Cross and Blue Shield Plans. (1996). Consumer’s guide for standard individual HMO and point of service coverage. Albany, N.Y: The Dept.
North Dakota Public Employees Retirement System., & BlueCross BlueShield of North
Dakota. (2000). Exclusive Provider Organization (EPO) and Preferred Provider Organization (PPO): Participating providers. Bismarck, N.D.: NDPERS.
United States. (1996). What Medicare beneficiaries need to know about Health
Maintenance Organizations (HMO) arrangements: Know your rights. Washington, D.C.: Dept. of Health and Human Services.