In today's health care market, a physician merely taking a patient's pulse requires insurance.
With the high costs of health care, most people in the United States, if asked, could not pay for an office visit or surgical procedure out of their own pockets; this is where health insurance comes in. However, with this coverage, the insurance company can controls patients' access to medical services. Common sense suggests that someone with insurance coverage will be more likely to access provider services which, in turn, increases utilization.
Limited Access without Insurance
If patients cannot afford to pay for medical services, either out-of-pocket or through insurance, health care providers can refuse to treat them. While most not-for-profit hospitals are required to provide some charity care to the poor or uninsured, in order keep their not-for-profit status, private practice physicians have no such restrictions. Accordingly, the absence of insurance can bar patients from receiving medical services.
Conditional Access with Insurance
Having insurance is not a guarantee of access. Different kinds of insurance set conditions on when, where and from whom access to medical services will be granted, such as HMO and MCO. Less restrictive is PPO coverage, where the patient must pay more but receives more choices in return; and Fee For Service (FFS) arrangements are made between the provider and patient when insurance coverage is not in place.
Health Maintenance Organization (HMO)
An HMO only treats those patients who are members of its health plan. The HMO's contract for care delivery with patients guarantees access to a primary care physician (PCP), who then determines access to specialists or hospitals. Each patient's primary care physician acts as a "gatekeeper" in this regard. Without the PCP's authorization, patients may be denied specialty care. Primary care physicians' financial compensation incentives are a factor affecting physicians' restricting patient access to specialty or experimental care.
Managed Care Organization (MCO)
Unlike HMOs, access to diagnosis and treatment with MCO insurance is determined by "formularies," which are lists of allowed treatments and prescription medications. Only those treatments specifically listed on the MCO's formularies are allowed. Other care and treatments are specifically not covered, and their cost will not be paid by the MCO.
Preferred Provider Organization (PPO)
A less restrictive and more open form of insurance coverage, in terms of access, is a Preferred Provider Organization (PPO). The patient does not have to select a gatekeeper PCP or use a list of formularies, but he does have to pay more for the privilege of using any doctor for any reason. There is a deductible which must be met yearly before the insurance begins to pay a percentage of the treatment cost. Moreover, the patient must pay extra to see a provider who is not in the plan's network of participating providers.
Contract Between Patient and Provider (FFS)
Before the advent of insurance, the original medical care delivery system was an arrangement between doctor and patient. Today, that system is called Fee For Service (FFS). The patient requests medical services. The doctor provides services. The doctor sends a bill. Although there are few insurance contracts today which cover patients on a Fee For Service basis, these arrangements can be made directly with the health provider's billing office, which charges the patient a "private pay" rate. This rate is the lowest price the provider will accept for a procedure without insurance reimbursement.
Relationship Among Insurance, Access and Utilization
While having insurance provides a means of paying for medical services, insurance coverage does not always guarantee access to services. However, without access to services, utilization is not possible.
Tags: medical services, health care, insurance coverage, access medical, access medical services
