This document provides an overview and comparison of two common health care payment systems: fee-for-service and capitation. Fee-for-service involves paying providers for each individual service rendered, which can incentivize overtreatment but allows for clinical autonomy. Capitation involves paying providers a fixed amount per patient per time period regardless of services rendered, which can incentivize under treatment of patients needing more care but removes profit motives. Both systems provide different cash flows and incentives to providers. The document also briefly discusses the U.S. health care system, including private insurance, Medicare, Medicaid, and the roles of individuals, businesses, government, and private insurers in financing care.
Chapter 18 Private and Government Healthcare Systems PriMorganLudwig40
Chapter 18
Private and Government Healthcare Systems
Private and Government Healthcare Systems
In the United States, health insurance coverage is generally classified as either private (non-government) coverage or government-sponsored coverage.
Healthcare Coverage vs. Uninsured
The National Center for Health Statistics defines health insurance as public and private payers who cover medical expenditures incurred by a defined population in a variety of settings.
In the United States, the risk of becoming uninsured increases significantly for those earning low wages, the unemployed, and when employers are unable to provide insurance to workers.
Table 5-2 presents the trend of declining health insurance coverage.
Private Health Insurance
The concept of insurance is to combine the healthcare experiences of many enrollees in order to reduce expenses for any one individual to a manageable prepayment amount.
Employment-Based Plans is coverage offered through one’s own employment or a relative’s employment.
It may be offered by an employer or by a union.
Private Health Insurance Continued
Direct-Purchase/Fee-For-Service Plans are the traditional type of healthcare policy.
The physician sets a price for each type of service delivered, and then the client or insurance company pays the fee.
This type of health insurance provides the most choices of doctors and hospitals.
Private Health Insurance Continued
The two kinds of fee-for-service coverage are basic and major medical.
Basic covers some hospital services and supplies, such as X-rays and prescribed medicine.
Major medical insurance covers the cost of long-term, high-cost illnesses or injuries plus whatever basic did not cover.
Private Health Insurance Continued
Group Contract Insurance—to make hospitals and physicians products and services affordable to ordinary people in the United States.
With unmanaged care (fee-for-service) payments, healthcare providers could increase the number of single services they deliver in order to increase profit.
Private Health Insurance Continued
Managed Care—manages the cost and delivery of healthcare services, the quality of that healthcare, and access to care.
Managed care influences how much healthcare clients can use.
Health Maintenance Organizations (HMOs) are prepaid health plans.
The goal of an HMO is to provide affordable, well-organized healthcare by allowing clients to prepay (capitation payment) on a regular monthly basis for all services provided.
Private Health Insurance Continued
Including physicians’ visits, hospital stays emergency care, surgery, laboratory (lab) tests, X-rays, and therapy for all members and their families.
There may be a small co-payment for each office visit, such as $15 for a doctor’s visit or $50 for hospital emergency room treatment.
Private Health Insurance Continued
Point-of-Service Plans (POS) offer enrollees the option of receiving services from participating or nonparticipating prov ...
While the health care reform bill is a step in the right direction, medicare for all or single payer is what is really needed to control costs and insure all.
Managed Care within Health Care covers a variety of information from nursing homes, policies, Medical, Medicare, out of pocket, and partial payment, management, contracts, government, and the Social Security State Fund. Within this working paper I will discuss a few of these mechanisms that are applied and utilized within ‘Managed Care’ today. A system within a system that brings in 25% of the United States debt.
Chapter 18 Private and Government Healthcare Systems PriMorganLudwig40
Chapter 18
Private and Government Healthcare Systems
Private and Government Healthcare Systems
In the United States, health insurance coverage is generally classified as either private (non-government) coverage or government-sponsored coverage.
Healthcare Coverage vs. Uninsured
The National Center for Health Statistics defines health insurance as public and private payers who cover medical expenditures incurred by a defined population in a variety of settings.
In the United States, the risk of becoming uninsured increases significantly for those earning low wages, the unemployed, and when employers are unable to provide insurance to workers.
Table 5-2 presents the trend of declining health insurance coverage.
Private Health Insurance
The concept of insurance is to combine the healthcare experiences of many enrollees in order to reduce expenses for any one individual to a manageable prepayment amount.
Employment-Based Plans is coverage offered through one’s own employment or a relative’s employment.
It may be offered by an employer or by a union.
Private Health Insurance Continued
Direct-Purchase/Fee-For-Service Plans are the traditional type of healthcare policy.
The physician sets a price for each type of service delivered, and then the client or insurance company pays the fee.
This type of health insurance provides the most choices of doctors and hospitals.
Private Health Insurance Continued
The two kinds of fee-for-service coverage are basic and major medical.
Basic covers some hospital services and supplies, such as X-rays and prescribed medicine.
Major medical insurance covers the cost of long-term, high-cost illnesses or injuries plus whatever basic did not cover.
Private Health Insurance Continued
Group Contract Insurance—to make hospitals and physicians products and services affordable to ordinary people in the United States.
With unmanaged care (fee-for-service) payments, healthcare providers could increase the number of single services they deliver in order to increase profit.
Private Health Insurance Continued
Managed Care—manages the cost and delivery of healthcare services, the quality of that healthcare, and access to care.
Managed care influences how much healthcare clients can use.
Health Maintenance Organizations (HMOs) are prepaid health plans.
The goal of an HMO is to provide affordable, well-organized healthcare by allowing clients to prepay (capitation payment) on a regular monthly basis for all services provided.
Private Health Insurance Continued
Including physicians’ visits, hospital stays emergency care, surgery, laboratory (lab) tests, X-rays, and therapy for all members and their families.
There may be a small co-payment for each office visit, such as $15 for a doctor’s visit or $50 for hospital emergency room treatment.
Private Health Insurance Continued
Point-of-Service Plans (POS) offer enrollees the option of receiving services from participating or nonparticipating prov ...
While the health care reform bill is a step in the right direction, medicare for all or single payer is what is really needed to control costs and insure all.
Managed Care within Health Care covers a variety of information from nursing homes, policies, Medical, Medicare, out of pocket, and partial payment, management, contracts, government, and the Social Security State Fund. Within this working paper I will discuss a few of these mechanisms that are applied and utilized within ‘Managed Care’ today. A system within a system that brings in 25% of the United States debt.
LECTUREUnit ObjectivesAfter completing this unit, you should b.docxgauthierleppington
LECTURE
Unit Objectives
After completing this unit, you should be able to
define
moral hazard
,
adverse selection
, and
cost-shifting
identify the major public programs for the financing of health care
compare and contrast Medicare and Medicaid
list and describe the four sub-programs of Medicare
describe different reimbursement approaches for health services
Unit Lecture
When asked how health care services are paid for, many of us think immediately of health insurance. However, we typically don't think about the dynamics behind health insurance or the various types of programs through which it is delivered. At its most basic level,
health insurance
is a tool for mitigating risk. An individual purchases health insurance to mitigate the risk of having to pay an enormous medical bill in the event of sickness or injury.
Those who provide health insurance—insurance companies—also work to mitigate risk, albeit from the other side. They attempt to create a risk pool containing a large number of healthy people to offset the expenses accrued by those who do get sick or injured.
Premiums
, the fees paid for ownership of health insurance, are used to subsidize the cost of the health care provided to those who use the insurance.
Factors that insurance companies need to be mindful of include
moral hazard
, whereby an insured individual is more prone to seek care than if he or she were paying the medical bill him- or herself; and
adverse selection
, whereby insurance is mainly purchased by those most in need of it. As with any financial enterprise, if the costs of providing the product or service exceed the revenue, the company goes out of business.
There are several types of insurance programs, both public and private. Together, these programs cover not only individual health services, but public health services, research, and the administration of the delivery and financing of health care in the United States. The majority of public and private expenditures—approximately 81 percent—are directed toward hospital care, provider and clinical services, long-term care, and prescription drug provision (Kovner & Knickman, 2011).
As mentioned in the week 4 lecture, health insurance is a relatively new mechanism for financing health services, and it has grown substantially since the mid-1900s, when only 9 percent of the US population had health insurance (Blumberg & Davidson, 2009). Health insurance can be broken down into private and public insurance.
Private health insurance
is primarily employment-based, meaning that individuals receive coverage through commercial health insurance plans for which their employers either pay the premiums or subsidize them, with the employee paying the balance.
Some larger employers choose to self-insure, which means that they administer their own plans and accept the financial risk of doing so. In essence, they act as the insurer of their employees.
Some individuals, either through necessity or choice, opt to purchase t.
A low cost alternative to meeting rising healthcare cost. Addresses the root causes of accelerating health care cost and solves the issue of rising healthcare cost.
1. Describe the role of finance in the healthcare system. The .docxjeremylockett77
1. Describe the role of finance in the healthcare system.
The role of finance in the healthcare industry is a major part of all decisions made for an organization. "Of course, the manner of financing healthcare affects how hospitals and physicians are reimbursed for services and hence has a significant influence on healthcare finance" (Gapenski, 2013, P. 5). Managers in the healthcare industry must have an up-to-date knowledge on the fundamentals of financing and be able to improve the finical wellbeing of their organization. Financing for a healthcare organization needs to include accounting and financial management functions to be successful. This allows for the measurements of an organizations financial performance and allows for an assessment of operations. "The primary role of finance in health services organizations, as in all businesses, is to plan for, acquire, and use resources to maximize the efficiency (and value) of the enterprise" (Gapenski, 2013, P. 6).
2. Describe the Diagnosis codes and how they are used, impacting reimbursement.
The International Classification of Diseases (ICD) is the typical resource for designating diseases, signs, symptoms, and external causes of injury (Gapenski, 2013). This resource was published by the World Health Organization (WHO). The application of these codes to diagnoses is technical. Hospital coders must understand the coding system, medical terminology and abbreviations used by clinicians, they must have proper training and experience. Proper reimbursement from third-party payers depends on accurate coding. Coding errors can greatly impact the reimbursement that the provider will receive for the services provided. Implementing proper coding techniques, training and detailed notes/test results in patients' notes can decrease medical coding mistakes in an organization.
3. Describe the features of third-party payers.
Third-party payers are insurers that reimburse health organizations for the health services provided to a patient. They are the major source of revenues for most providers. These organizations help to reduce the financial burden associated with illness and injury. Third-party payers fall into two categories, private insurers (Blue Cross Blue Shield) and public programs (Medicare and Medicaid). Different payment resources depend on what type of category the insurance falls into, if providers are preferred providers, and what services were provided.
A. Private Insurers: Blue Cross Blue Shield is an example of a private insurer. Coverage for specific provider services are covered by paying a monthly monetary fee through a chosen plan.
B. Public Programs: “Government is both a major insurer and a direct provider of healthcare services” (Gapenski, 2013, P. 65). They provide healthcare services directly to qualifying individuals through organizations such as the Department of Veterans Affairs, Department of Defense, and Public Health Departments. They are one of the major insurers in ...
hapter 5What Are the Governmental AlternativesThe United StatJeanmarieColbert3
hapter 5
What Are the Governmental Alternatives?
The United States has tried an alphabet soup of health policy options: HSAs, HMOs, IPAs, PPOs, POS plans, ACOs, and so on. Health care analysts often must look beyond specific organizational and financial alternatives and address issues at a higher level and deal with the threads of economic and political thought behind different proposals while considering the overall criteria of access, cost, and quality of care.
Politicians and businesspeople from outside the health care sector advocate many alternatives. To offset their tendency to ignore professional issues, in this chapter we discuss alternatives affecting professional status and roles and institutional responses to them. Table 5-1 presents an array of federal alternatives organized by their primary criteria—access, quality, or cost—and then by the economic philosophies behind them. The items in this array are not intended to be either mutually exclusive or collectively exhaustive; rather, the table provides a framework for looking at both the broad policy picture and specific health care actions taken at various times and places. Later in the chapter, another table (Table 5-3) summarizes policy alternatives added by state and local governments. Many of these alternatives were included as provisions of the Affordable Care Act (ACA). They are still included here, partly because they may be subject to reconsideration in the future.
Table 5-1 Illustrative Federal Government Health Policy Options
Access to Care
• Administered systems
• Universal coverage
• Expand or reduce eligibility or benefits
• Mandate coverage and services
• Captive providers
• Control insurance industry practices
• Mandate employer-based insurance coverage
• Consumer-driven competition
• Implement insurance exchanges
• Encourage basic plans with very low premiums for low-income workers and “young invincibles”
• Mandate individual coverage
• Allow states flexibility to reallocate federal funds for vouchers
• Oligopolistic competition
• Expand or contract coverages in entitlement and categorical programs
• Allow states to reallocate federal uncompensated care funds
• Eliminate ERISA constraints on the states
• Expand the capacity of the system
Quality of Care
• Administered system
• Mandate participation in quality improvement efforts in federal plans and programs
• Add more pay-for-performance incentives
• Select providers and programs on the basis of quality excellence
• Consumer-driven competition
• Encourage or mandate transparency of quality reporting in federal plans and programs
• Oversee licensure and credentialing of foreign-trained providers
• Oligopolistic competition
• Work reporting of quality care and adverse events into purchasing specifications for federal programs and disseminate to the public
• Encourage wider use of health information technology
Cost of Care
• Administered system
• Use full bargaining power in negotiation of ...
POSITION PAPER
POSITION PAPER 2
Position Paper
Candice Jacobs
Strayer University
PAD 510: Introduction to Public Policy Analysis
Instructor: Dr. Timothy Smith
Argument in Favor of the Policy
The affordable healthcare policy was enacted by Congress to address the issues of healthcare affordability and accessibility in the in the United States. This policy was aimed to remove the barriers that existed in the country in accessing healthcare services by the elderly and low-income earners. This policy has significant benefits to the American people. It provides subsidies which make healthcare affordable to all Americans. The policy has also made prescription drugs to cost less. This makes it possible for people, especially the low-income earners, to afford these drugs (Andrews et al., 2015).
Most Americans are now able to access healthcare insurance at affordable prices as a result of the implementation of the policy. It has also made it possible for people with preexisting conditions such as cancer to get health insurance, which helps them access healthcare at affordable prices (Blumenthal, Abrams & Nuzum, 2015). Before the policy was implemented, such people couldn't get healthcare insurance covers. Mores screening is also covered as a result of the implementation of the policy. People are screened and start their treatment early enough to prevent costly treatment at later stages of the disease.
Normative Argument
This policy ought to be improved to meet its objectives. The government ought to expand the subsidies to make coverage more affordable for low-income earners. Outreach and education also ought to be increased enrollment. Most people are unable to access affordable healthcare due to lack of education. Payment to doctors and hospitals also need to be capped to reduce premiums (Burgin, 2018). The individual mandate should also be replaced to prevent catastrophic costs to the buyers. The employer mandate should also be killed. This will significantly improve the benefits of the policy to all Americans.
Argument against the Policy
The affordable healthcare policy has affected Americans negatively in many ways. First, most people have to pay higher premiums. Most insurance organizations provide numerous benefits which make them more expensive for people who already had been insured. People can also be fined if they do not have insurance. This policy requires people to pay insurance each year. If you don’t pay, you may be fined. People believe that if one does not pay insurance, they are passing healthcare burden to those that pay (Béland, Rocco & Waddan, 2015).
The affordable healthcare policy is also increasing taxes. Several taxes were passed into law to help pay for the policy. More taxes were also imposed for higher-income earners. The wealthy are losing their money to fund the program. When the affordable healthcare website was being launched, it experienced various cha ...
LECTUREUnit ObjectivesAfter completing this unit, you should b.docxgauthierleppington
LECTURE
Unit Objectives
After completing this unit, you should be able to
define
moral hazard
,
adverse selection
, and
cost-shifting
identify the major public programs for the financing of health care
compare and contrast Medicare and Medicaid
list and describe the four sub-programs of Medicare
describe different reimbursement approaches for health services
Unit Lecture
When asked how health care services are paid for, many of us think immediately of health insurance. However, we typically don't think about the dynamics behind health insurance or the various types of programs through which it is delivered. At its most basic level,
health insurance
is a tool for mitigating risk. An individual purchases health insurance to mitigate the risk of having to pay an enormous medical bill in the event of sickness or injury.
Those who provide health insurance—insurance companies—also work to mitigate risk, albeit from the other side. They attempt to create a risk pool containing a large number of healthy people to offset the expenses accrued by those who do get sick or injured.
Premiums
, the fees paid for ownership of health insurance, are used to subsidize the cost of the health care provided to those who use the insurance.
Factors that insurance companies need to be mindful of include
moral hazard
, whereby an insured individual is more prone to seek care than if he or she were paying the medical bill him- or herself; and
adverse selection
, whereby insurance is mainly purchased by those most in need of it. As with any financial enterprise, if the costs of providing the product or service exceed the revenue, the company goes out of business.
There are several types of insurance programs, both public and private. Together, these programs cover not only individual health services, but public health services, research, and the administration of the delivery and financing of health care in the United States. The majority of public and private expenditures—approximately 81 percent—are directed toward hospital care, provider and clinical services, long-term care, and prescription drug provision (Kovner & Knickman, 2011).
As mentioned in the week 4 lecture, health insurance is a relatively new mechanism for financing health services, and it has grown substantially since the mid-1900s, when only 9 percent of the US population had health insurance (Blumberg & Davidson, 2009). Health insurance can be broken down into private and public insurance.
Private health insurance
is primarily employment-based, meaning that individuals receive coverage through commercial health insurance plans for which their employers either pay the premiums or subsidize them, with the employee paying the balance.
Some larger employers choose to self-insure, which means that they administer their own plans and accept the financial risk of doing so. In essence, they act as the insurer of their employees.
Some individuals, either through necessity or choice, opt to purchase t.
A low cost alternative to meeting rising healthcare cost. Addresses the root causes of accelerating health care cost and solves the issue of rising healthcare cost.
1. Describe the role of finance in the healthcare system. The .docxjeremylockett77
1. Describe the role of finance in the healthcare system.
The role of finance in the healthcare industry is a major part of all decisions made for an organization. "Of course, the manner of financing healthcare affects how hospitals and physicians are reimbursed for services and hence has a significant influence on healthcare finance" (Gapenski, 2013, P. 5). Managers in the healthcare industry must have an up-to-date knowledge on the fundamentals of financing and be able to improve the finical wellbeing of their organization. Financing for a healthcare organization needs to include accounting and financial management functions to be successful. This allows for the measurements of an organizations financial performance and allows for an assessment of operations. "The primary role of finance in health services organizations, as in all businesses, is to plan for, acquire, and use resources to maximize the efficiency (and value) of the enterprise" (Gapenski, 2013, P. 6).
2. Describe the Diagnosis codes and how they are used, impacting reimbursement.
The International Classification of Diseases (ICD) is the typical resource for designating diseases, signs, symptoms, and external causes of injury (Gapenski, 2013). This resource was published by the World Health Organization (WHO). The application of these codes to diagnoses is technical. Hospital coders must understand the coding system, medical terminology and abbreviations used by clinicians, they must have proper training and experience. Proper reimbursement from third-party payers depends on accurate coding. Coding errors can greatly impact the reimbursement that the provider will receive for the services provided. Implementing proper coding techniques, training and detailed notes/test results in patients' notes can decrease medical coding mistakes in an organization.
3. Describe the features of third-party payers.
Third-party payers are insurers that reimburse health organizations for the health services provided to a patient. They are the major source of revenues for most providers. These organizations help to reduce the financial burden associated with illness and injury. Third-party payers fall into two categories, private insurers (Blue Cross Blue Shield) and public programs (Medicare and Medicaid). Different payment resources depend on what type of category the insurance falls into, if providers are preferred providers, and what services were provided.
A. Private Insurers: Blue Cross Blue Shield is an example of a private insurer. Coverage for specific provider services are covered by paying a monthly monetary fee through a chosen plan.
B. Public Programs: “Government is both a major insurer and a direct provider of healthcare services” (Gapenski, 2013, P. 65). They provide healthcare services directly to qualifying individuals through organizations such as the Department of Veterans Affairs, Department of Defense, and Public Health Departments. They are one of the major insurers in ...
hapter 5What Are the Governmental AlternativesThe United StatJeanmarieColbert3
hapter 5
What Are the Governmental Alternatives?
The United States has tried an alphabet soup of health policy options: HSAs, HMOs, IPAs, PPOs, POS plans, ACOs, and so on. Health care analysts often must look beyond specific organizational and financial alternatives and address issues at a higher level and deal with the threads of economic and political thought behind different proposals while considering the overall criteria of access, cost, and quality of care.
Politicians and businesspeople from outside the health care sector advocate many alternatives. To offset their tendency to ignore professional issues, in this chapter we discuss alternatives affecting professional status and roles and institutional responses to them. Table 5-1 presents an array of federal alternatives organized by their primary criteria—access, quality, or cost—and then by the economic philosophies behind them. The items in this array are not intended to be either mutually exclusive or collectively exhaustive; rather, the table provides a framework for looking at both the broad policy picture and specific health care actions taken at various times and places. Later in the chapter, another table (Table 5-3) summarizes policy alternatives added by state and local governments. Many of these alternatives were included as provisions of the Affordable Care Act (ACA). They are still included here, partly because they may be subject to reconsideration in the future.
Table 5-1 Illustrative Federal Government Health Policy Options
Access to Care
• Administered systems
• Universal coverage
• Expand or reduce eligibility or benefits
• Mandate coverage and services
• Captive providers
• Control insurance industry practices
• Mandate employer-based insurance coverage
• Consumer-driven competition
• Implement insurance exchanges
• Encourage basic plans with very low premiums for low-income workers and “young invincibles”
• Mandate individual coverage
• Allow states flexibility to reallocate federal funds for vouchers
• Oligopolistic competition
• Expand or contract coverages in entitlement and categorical programs
• Allow states to reallocate federal uncompensated care funds
• Eliminate ERISA constraints on the states
• Expand the capacity of the system
Quality of Care
• Administered system
• Mandate participation in quality improvement efforts in federal plans and programs
• Add more pay-for-performance incentives
• Select providers and programs on the basis of quality excellence
• Consumer-driven competition
• Encourage or mandate transparency of quality reporting in federal plans and programs
• Oversee licensure and credentialing of foreign-trained providers
• Oligopolistic competition
• Work reporting of quality care and adverse events into purchasing specifications for federal programs and disseminate to the public
• Encourage wider use of health information technology
Cost of Care
• Administered system
• Use full bargaining power in negotiation of ...
POSITION PAPER
POSITION PAPER 2
Position Paper
Candice Jacobs
Strayer University
PAD 510: Introduction to Public Policy Analysis
Instructor: Dr. Timothy Smith
Argument in Favor of the Policy
The affordable healthcare policy was enacted by Congress to address the issues of healthcare affordability and accessibility in the in the United States. This policy was aimed to remove the barriers that existed in the country in accessing healthcare services by the elderly and low-income earners. This policy has significant benefits to the American people. It provides subsidies which make healthcare affordable to all Americans. The policy has also made prescription drugs to cost less. This makes it possible for people, especially the low-income earners, to afford these drugs (Andrews et al., 2015).
Most Americans are now able to access healthcare insurance at affordable prices as a result of the implementation of the policy. It has also made it possible for people with preexisting conditions such as cancer to get health insurance, which helps them access healthcare at affordable prices (Blumenthal, Abrams & Nuzum, 2015). Before the policy was implemented, such people couldn't get healthcare insurance covers. Mores screening is also covered as a result of the implementation of the policy. People are screened and start their treatment early enough to prevent costly treatment at later stages of the disease.
Normative Argument
This policy ought to be improved to meet its objectives. The government ought to expand the subsidies to make coverage more affordable for low-income earners. Outreach and education also ought to be increased enrollment. Most people are unable to access affordable healthcare due to lack of education. Payment to doctors and hospitals also need to be capped to reduce premiums (Burgin, 2018). The individual mandate should also be replaced to prevent catastrophic costs to the buyers. The employer mandate should also be killed. This will significantly improve the benefits of the policy to all Americans.
Argument against the Policy
The affordable healthcare policy has affected Americans negatively in many ways. First, most people have to pay higher premiums. Most insurance organizations provide numerous benefits which make them more expensive for people who already had been insured. People can also be fined if they do not have insurance. This policy requires people to pay insurance each year. If you don’t pay, you may be fined. People believe that if one does not pay insurance, they are passing healthcare burden to those that pay (Béland, Rocco & Waddan, 2015).
The affordable healthcare policy is also increasing taxes. Several taxes were passed into law to help pay for the policy. More taxes were also imposed for higher-income earners. The wealthy are losing their money to fund the program. When the affordable healthcare website was being launched, it experienced various cha ...
Similar to A Comparison of Health Care Payment Systems.pdf (11)
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1. A Comparison of Health Care Payment Systems
A Comparison of Health Care Payment SystemsSeptember 8, 2012 Health care workers are
compensated for their services through various means. The commonly used methods for
calculating the expected amounts are fee for service (FFS) and capitation. Any of the system
which is adopted strives to provide the best health care services to members of the
public.Fee for service program is a traditional method of payment. The amount paid to a
patient is determined by the nature of services being rendered to the individual. In cases
where more services are rendered to a patient, they end up paying extra costs. The
compensation for the services may be done by the individual, insurance company or a
government program. This program dictates for a specific amount to be paid for services
rendered as opposed to retainer, a salary or any other contractual agreements. This
program provides patients with complete care which is advantageous to their wellbeing.
Also, the physicians benefit for they have the clinical autonomy to charge their services
without any restrictions (Williams 2008).Fee for service is mainly used for physician
remunerations after offering a service to a patient. However, it is accused of giving the
physician an incentive for him or her to provide minimum care to an affected patient.
Provision of poor services will allow the professional to see more patients within a short
span of time. The more the patients, the higher the expected pay from rendering the
services. The services can be expensive for patients to pay for since the physician has the
autonomy to charge any costs. Through this program, the administration is extremely
complex and inflexible. Therefore, it is difficult to adapt to changes in the working
environment.In capitation, a specific amount is paid to health workers periodically
regardless of the quantity of services they have rendered to the patients. Each professional
is paid a fixed amount for every patient they have served. In this, they do not consider the
number of services you have provided or nature delivered. A fixed amount of compensation
may also be provided depending on the time span that one has delivered the services like a
year or a month (Shi, 2010)The amount to be paid to the health provider depends on sex,
age and even the area of residence of the patient. In this program, the compensation is
usually calculated in advance which may depend on population and regardless of the health
condition of the patient. This program removes the incentive of treating more patients as in
the case of fee for service program. This program enhances better service provision to
patients as the profit motive from medical practitioners is almost eliminated. Profit making
motive is no longer the driving factor but a better service provision to patients (Williams,
2008). At the same time, this may encourage the health providers to include healthy people
2. into their patient files who do not need any care. This will help in boosting the level of gains
even though it is against the law. The health providers will be compensated the same
amount for patients who need either minimum or maximum care. Neglect is evident to
those who need maximum care and majorly focus on those who need minimum care to
increase the number of patients one is attending. Both scenarios of capitation and fee for
the service offer different cash flows to the economy. Capitation offers a fixed amount of
compensation based on the number of members and regardless of the number of visits
while fee for service is different since the amount is based on the number of visits
(Wurman, 2004).The US health care system is considered the best health care service
providers in the world due to the availability of improved technologies and facilities. The
system has both private and public insurers to cater for the poor and low income earners.
The main way of private insurers is through employer sponsored insurance covers provided
privately.Public health insurance can be provided through Medicaid or Medicare. Medicare
is a program that caters for individuals with ages above 65 and the disabled. It is usually
administered by the government through revenues collected. On the other hand, Medicaid
caters for the low income earners and the disabled. It is financed through revenues
collected as taxes from the US citizens. Private health insurance is through employer
sponsored insurance and the private non group insurance. Employers provide insurance
covers to their workers as part of benefits package through the employer sponsored
insurance covers. The private non group insurance covers those either retired or self-
employed (Williams, 2008).The financing of the health care system centers between
collecting money from members of public for health care (money going in) and provision of
the service to its members (money going out). In the US, the two responsibilities are done
by private insurance companies and the government without the exception of individuals
and businesses. Individuals and businesses finance the health care system through payment
of taxes, premiums and direct out of pocket payments. They both pay taxes levied by the
government and payroll taxes for financing Medicare. Premiums can be paid either to
employer based insurance or directly to private insurers. A patient can also pay directly to a
service provider for a service he or she has been served.The US government finances the
health care system through Medicaid, Medicare, public employees’ premiums and tax
subsidy. The government uses taxes levied to compensate health care providers for services
they have provided to its citizen through the Medicaid and Medicare programs. Public
employees’ premiums are used to cater for federal employees and any other public servants
serving within the government. Tax subsidy is a case where the health care benefits are tax
free and the health care benefits are included as part of cost for doing business.Private
insurers also serve a critical role in the financing of for services provided to patients by the
medical practitioners. They take premiums from individuals and later help clear any bills
which arise from service provision. Private insurers may also accept premiums from
businesses and government.For the provision of their services, health providers get
compensated in terms of payments. Payments can be done directly by the affected
individual, insurance covers either private or public and even the government. The US
government should mainly strive to ensure smooth service provision and a clean payment
mechanism. The government should ensure quality service provision at the correct price.
3. Therefore, the government’s role is to mainly facilitate the entire process is smooth and
efficient. The flow of finances from the individual is made smooth through the
intermediation of government, private insurers and public health
insurers. References:Raffel, M.W. (2011). U. S. Healthcare System (6th ed.). Delmar
Publications.Shi, L. & Singh, D. (2010). Essentials of the U.S. health care system (2nd ed.).
Sudbury, MA:Jones and Bartlett Publishing.Williams, S. & Torrens, P. (2008). Introduction to
health services (7th ed.). Albany, NY: DelmarCengage.Wurman, R. S. (2004). Understanding
Healthcare. Top publishers. “Looking for a Similar Assignment? Get Expert Help at an
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