Now let's look at the U.S. health care system related to reimbursement issues. Historically, three factors are driving U.S. health care reform:
 Access to care
Quality of care
Cost of care
This module section will focus on the cost of care. Here are some facts:
The United States has an employer-based health care reimbursement system
- This is unlike most developed countries, where health care is provided to their citizens through universal entitlement.
Since large numbers of consumers of health care are not employed (e.g., children, the sick, the elderly) the U.S.
has a complex system of multiple providers and payers.
Typically, Americans tend to believe "someone else" is paying the health care bill
- The actual costs of health care are rarely revealed to the consumers of that care, whether they are insured or uninsured. However, Americans are worried about access, cost and quality!
Each state's insurance commission oversees the insurance companies
- Practices vary from state-to-state, despite the fact that companies
may do business across state lines.
The traditional fee-for-service system is rapidly disappearing in U.S.
- This is particularly true in Minnesota where 80-90% of providers
practice in large group practices. Fee-for-service is being replaced
by managed care/managed competition systems of care. In managed care
systems, practices have to negotiate on an annual basis for the price
of care. The element of competition for contracts between managed
care systems means that providers are frequently asked to accept discounted
reimbursement for the care provided.
Minnesota does not permit "for profit" managed care organizations
- Some for-profit organizations have their headquarters in Minnesota
but carry out their operations in other states (e.g., United HealthCare
Co.)
Mergers are creating regional national non-profit and for-profit corporations
- These are "integrated service networks" and have all levels of care under one corporate structure (e.g., primary care clinics, secondary and tertiary care centers)
Large health care organizations have larger pools of capital, so they:
- Use economy of scale measures to increase profits (e.g., buying supplies in bulk, marketing for an entire system, negotiating contracts for entire systems, etc.)
- Focus on the bottom line profitability because of responsibility to shareholders
- Compete for employer contracts in a highly volatile market
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