Healthcare System Overview No.9
Healthcare system overview
Healthcare system overview I’m here with academic Laurence Baker at StanfordMedical faculty. And what we’re progressing to quote now could be the summary of the health care system. LAURENCE BAKER: what’s the health care system.
Yea, and who’s in it? LAURENCE BAKER: And who’s in it? And what square measure they doing? I feel I may provide a go at it. LAURENCE BAKER: choose it. and so corrects American state.
Expose my mental object. So clearly, you’ve got your suppliers. Those would be your doctors, and nurses, and every one the remainder. LAURENCE BAKER: Hospitals, pharmacies, all types of individuals square measure your suppliers.
Thus everybody who’s providing health care. thus that is right over there. thus that is hospitals, doctors, pharmacies, all the remainder. Healthcare system overview and so they’re providing health care to somebody.
Thus those would be the patients. Let the American state do this in another color. LAURENCE BAKER: decision them, patients. Yeah, generally you get the main points like individuals to become patients when they have health care.
However, some individuals simply have an issue. they don’t seem to be real patients, they are simply asking. Healthcare system overview What would your decision them then? LAURENCE BAKER: decision them population.
Population. thus simply the population of the globe, or of the country, or whatever– individuals. and so somebody must acquire this. so for the foremost half, this can be insurers. LAURENCE BAKER: Yup.
Insurance firms. within the past days–like if you return one hundred years– we have a tendency to did not extremely have insurers. Healthcare system overview we have a tendency to had patients and suppliers.
And patients would– if that they had an issue, that they had a priority, they’re going to the supplier. Healthcare system overview They’d create some deal, pay them some cash, do some service for them, and work it out.
We have a tendency to got insurance firms extremely solely within the last100 years, maybe. extremely beginning within the USA in perhaps 1930. Healthcare system overview 1940, they began to become standard.
Thus that is quite a brand new renovation. and people 3 things work along. and also the general term– and this can be a word I’ve seen tons, and generally it is a very little confusing as a result of it’s totally about to the remunerator.
You hear of those payors. which would be together with anyone who’s paying for the service. And insurance firms would be enclosed there. Healthcare system overview LAURENCE BAKER: Right.
Thus we have a tendency to have– we have a tendency to decision them payors. generally, we have a tendency to decision them health plans as a result of they prepare for a few of the care that folks get.
And payors may well be personal insurance firms, or they might be government payors– government insurance firms like health care. Healthcare system overview and also the insurance firms themselves.
They don’t seem to be doing this out of the goodness of their heart. somebody is paying them. And for the foremost half within us, Healthcare system overview it tends to be employers. LAURENCE BAKER: thus right.
Thus if we have a tendency to created another arrow on your diagram here, it’d be from the population– or even from the patients–to the insurance firms that give the money for the insurance firms to use to acquire the supplier.
Thus patients would possibly obtain AN insurance firm– or not AN insurance company, obtain AN policy. given that they are all right well. LAURENCE BAKER: a number of them obtain the full issue.
However, they simply would possibly obtain their own policy. Go obtain AN policy, pay them a premium directly, the insurance firm collects that cash. Healthcare system overview Or, for many individuals, they work for AN leader.
The leader makes the arrangement to shop for that insurance and so implicitly charges the population, Healthcare system overview the patients for that. perhaps directly by having them contribute a number of their salaries.
Perhaps implicitly by simply reducing the quantity of money they furnish them monthly, and rather than giving them this policy. thus individuals do this. and also the different piece that floating around here is that in some cases.
The population pays taxes to the govt. that then functions basically as AN insurance underwriter, just like the health care program, wherever there is insurance provided to individuals that are purchased by taxes.
Thus their square measure some totally different funds flow going around here, however perpetually cash going from patients to insurers, Healthcare system overview through employers from taxes, by direct payments.
Those insurers assembling the money and so paying for a bunch of the care that is provided by the suppliers. Healthcare system overview and that is the fundamental arrangement. there is an additional little piece.
That is that generally, patients pay the doctors or the hospitals directly. You go you’ve got a $20 co-payment. Healthcare system overview so there is a little payment that goes back and forth.
Your copay is quite there with great care that– it quite makes the insurance firm feel smart that you are not simply victimization it willy-nilly– that you simply got to pay your $10 or $50. LAURENCE BAKER: completely.
Thus insurers recognize that when they begin paying the suppliers for the care, and also the patient says it’s very free, Healthcare system overview individuals would possibly use stuff which may be value a bit little bit.
However, it prices tons for everyone to acquire. thus if you place a co-payment on there, Healthcare system overview it makes individuals moot concerning victimization things that they do not really want. Right.
That creates complete sense. and so at intervals this ecosystem–we hear tons concerning HMOs. Healthcare system overview My perception is that is a mixture of the insurance firm and also the supplier.
It’s quite in one package. LAURENCE BAKER: Right. So over time, the US has had different types of insurers out there. within the private market, especially, there’s been plenty of innovation within the last 30, 40 years within the kinds of insurers that are out there.
So we’ve different insurers that have behaved in numerous ways as we’ve well-versed those evolutionary cycles. So one version Healthcare system overview of that’s what we call an HMO– a health maintenance organization.
And that is really just jargon. you have got to perforate it to work out what it means. But in a very lot of cases, what that’s could Healthcare system overview be a company that acting as insurance.
So you pay a premium to them if you are a patient or someone, and you get some coverage. and so they’ll cover your care. Healthcare system overview But they’ll do this by trying to integrate themselves with the providers.
Then the organizations either are integrated because the HMO hires doctors directly or even owns the hospitals– like KaiserPermanente, as an example. Healthcare system overview Or, in some cases, it is a contractual relationship.
It isn’t precisely the same. So not all of them are tightly linked as a Kaiser, where it’s like, you goto this building that claims Kaiser on that. Healthcare system overview and that is where your doctor is.
It can be doctors just have their practices, but they’re tightly linked with a– I feel that’s how what Blue Shield? Or one among those. LAURENCE BAKER: Yeah, Blue Shield, or Aetna, or a number of these different companies.
And you’ll be able to start to perforate the small print and everybody are going to be a bit different from the opposite, Healthcare system overview but they’re contractual relationships.
And also the difference– I believe this is often something everyone faces after they sign on with insurance with their employer– I had to try and do it recently–is– all of them say, you’ve got to select HMO versus PPO.
And they are within the identical policy. so my perception is HMO is you have got a group list of doctors that they probably-negotiated pricing with. Healthcare system overview LAURENCE BAKER: Yeah.
Therefore the difference between HMOs and PPOs gets a bit into the small print OK. I do not want to urge too into– LAURENCE BAKER: we are able to form of giving some thought to it within the way that you’re talking about it.
So an HMO will have an inventory of doctors that you’re speculated to see. and you may go see the doctors on its list. And a stereotypical one, Healthcare system overview if you do not see the doctors thereon list.
The insurance company’s not visiting purchase your care, you are going to procure yourself. And within the stereotypicalHMO, there’s visiting be reasonably tight management between the nondepository financial.
Institution and therefore the doctors about what is going on to be done, what allowable, and so on. And within the most tightly linked case, they’ll be identical. The doctors are going to be employed by corporate.
That’s like Kaiser. LAURENCE BAKER: As you think that about it as a spectrum if you progress a bit removed from that to a PPO. What’s happening ina PPO is you are still visiting get a listing.
So you are going to be encouraged to determine those doctors, but maybe it’ll be a touch more flexible. Like, if you made the decision to not see someone on the list, the plan would still pay some amount.
Maybe not the maximum amount as they’d if you saw someone on a listing, but something. Whereas in an HMO, maybe nothing. and therefore the plan will probably work a touch less hard at managing what those doctors do to undertake and limit access to, say, high-cost services.
HMO will tend to figure harder, PPO tends to figure a touch less hard. So it is a bit of a spectrum. Healthcare system overview You’re reasonably moving from more managed and more concentrated to a bit less managed, but still.
More so than the system we had, say, within the ’50s or ’60s, where anybody visited any doctor, and any doctor did whatever they wanted. and also the insurer just paid the bill, and there was no integration.
So it is a bit of a– So that’s the main motivation why insurance companies try to induce more integrated with the providers, is because– a bit like you said, within the ’50s and ’60s, you’ve got the provider providing a service.
And clearly, the patient likes the service. and so you have got a 3rd party paying for it. and then there is no check on– the person deciding and therefore the person getting it says, yeah, let’s get more service.
And somebody else is– right. LAURENCE BAKER: So we created an enormous issue. Healthcare system overview Insurance companies are quite a motivating thing within the health policy world.
Because we’ve got to possess them. we’ve to own them to manage the chance related to getting sick. You get sick today and to induce a large bill. so we won’t leave people on their own for that.
We need to have insurance companies. But as soon as you create insurance companies, and that I can have, implicitly, Healthcare system overview all my neighbors obtain the healthcare that I would like.
Then I would start using things that end up being efficient. and then you bought to own the– insurance companies. Healthcare system overview But you bought to manage what happens once you have them also.
And then that is the integration between providers or co-payments and utilization review, and every one of these items, are basically attempts by insurance companies to undertake and manage what economists would call the financial loss.
The using additional services that you simply don’t necessarily need because everybody else goes to buy it for you. Healthcare system overview It makes complete sense. Well, thanks. that creates a lot of sense.