Today, I would like to introduce the current model of healthcare. It is the FOR-PROFIT HEALTHCARE INSURANCE MODEL. That model has three prominent components and one behind the scenes. Let me introduce those players under a little different name.
THE FIRST PARTY
The FIRST PARTY is the PROVIDER OF HEALTHCARE. Under federal regulations, a “health care provider” is defined as: a doctor of medicine or osteopathy, podiatrist, dentist, chiropractor, clinical psychologist, optometrist, nurse practitioner, nurse-midwife, or a clinical social worker who is authorized to practice and performing within the scope of their practice as defined by law.
There is a broader definition. Any entity from whom the For-Profit Health Care Insurance Model will accept medical certification to substantiate a claim for benefits.
By this definition a health care provider is a person or company that provides a health care service to you. In other words, your health care provider takes care of you.
- The physical therapist that helps you to recover from your knee injury.
- The Home Health Care Company that provides your visiting nurse.
- The durable medical equipment company that provides your home oxygen or wheelchair.
- Your pharmacy.
- The laboratory that draws and processes your blood tests.
- The imaging facility that does your mammograms, X-rays, and MRI scans.
- The speech therapist that works with you to make sure you can swallow food safely after a stroke.
- The outpatient surgery clinic where you had your colonoscopy done.
- The specialty laboratory that does your DNA test.
- The urgent care center or walk-in clinic in your neighborhood shopping center.
- The hospital where you receive inpatient (or in some cases, outpatient) care.
Each has its own master list of charges for different services. These charges are different from provider to provider.
That said, YOU become THE SECOND PARTY.
The SECOND PARTY is also known as the HEALTHCARE CONSUMER.
And where do you “consume” your healthcare? I am glad that you asked. Let me introduce you to the THIRD PARTY in our current For-Profit Health Care Insurance Model.
Euphemistically called the HEALTHCARE PAYOR. I call it euphemistically because not all HEALTHCARE CONSUMERS actually have some one else paying the bill directly. Let me be clear. We HEALTHCARE CONSUMERS are all paying the bill in many ways, but at the end of the day we tend to be identified as playing on the team which pays our bills. There are six such teams of HEALTHCARE PAYORS.*
- 49% paid for by the Employer (147 million of us)
- 19% paid through Medicaid (74.4 million)
- 14% paid through Medicare (57 million)
- 9% Uninsured (27.5 million)
- 7% self paid through ACA Marketplace (non group) (17.6 million)
- 2% paid through VA/TRICARE (8.1 million)
(*=approximate numbers based on multiple sources)