How could you use this knowledge in your work as a health coach?
Reflect on a particular topic from this week’s readings/videos that broadened your understanding of health insurance. Describe specifically what you learned. How could you use this knowledge in your work as a health coach? ————————————————————————————— HEALTH INSURANCE Health insurance in its most basic form is a shared risk pool that offers payment for medical services. Health insurance does not fit the criteria of a typical insurable good, like a car or a house. Since “health” is not a product but a dynamic, and at times, unpredictable state, it is different from typical commodities that are insured. Can you think of other ways that health insurance is different from other insurable goods? The basic concept behind insurance is to create a large pool to distribute risk. Insurance companies are able to cover the medical bills of a small number of costly utilizers through the contributions of everyone in the pool. Health insurance and medical services don’t function by the same principles of supply and demand that are part of the . economy. Healthcare financing in the . is conducted mostly by third-party organizations, such as health insurers or managed care organizations (MCOs). MCOs and insurance companies often purchase services in bulk from hospitals or pharmacy chains or large physician groups. This allows third-party payers to negotiate terms on the behalf of their members. Until recently, the cost for services affiliated with hospitals has not been made public or transparent to consumers but that is changing as pricing becomes more transparent. (Links to an external site.) According to USAFacts (Links to an external site. more than half of all insured individuals get their health insurance from employer-based coverage. Also, over two-thirds of Americans get their health insurance from private or commercial insurers. According to the Peter G. Peterson Foundation (Links to an external site. In 2020, 19% of Americans were insured by Medicare. If you are interested in seeing a breakdown of the types of insurance coverage across the ., the CDC publishes data on the National Center for Health Statistics (Links to an external site. READ: 1.) Perrin textbook, Principles of Health Navigation, Ch. 6 () 2.) . Health Insurance Coverage in 2020: A Looming Crisis in Affordability Managed Care Organizations Managed care is a system of healthcare delivery directed at saving costs. It is the most common healthcare delivery system in the . and is available to most Americans. There are three main types of managed care organizations, including health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point of service (POS) plans. These different types of managed care plans attempt to reduce utilization and control costs. MCOs provide healthcare services through contracted (or a network of) providers (hospitals, doctors, clinics) with the health plan for enrollees of the plan. HMOs have copays, more restricted networks and typically require that patients stay in-network. With HMOs, the PCP or GP is the gatekeeper that patients must see first before being referred to specialists. This often means longer wait times to see a PCP or GP because of the high demand for appointments. With HMOs there can also be delays for PCPs to refer to specialists. For example, a patient who has a newly fractured toe needs to see an orthopedic surgeon for evaluation, the patient would need to see their PCP, then wait for pre-authorization/ approval from the insurance, then for the referral to be received by the surgeon’s office. This process could take one or more weeks to complete! Read more on How Referrals Work (Links to an external site. this VeryWellHealth article. PPOs generally have fewer copays, and allow out of network access, usually at a higher cost to the enrollee. Because PPOs are more flexible and provide broader provider options, they have been more popular than HMO plans. In general, an enrollee will pay less for care if they stay within the network of doctors and hospitals that are part of the plan. With PPOs, it is also generally easier to get an appointment with a provider. Although the enrollee can see specialists in-network with more flexibility, they still need a PCP’s referral. There are other types of health plans, including EPOs (exclusive provider organization) and POS (point of service). You can read more about health plans in this article from Web MD Health Insurance Plans (Links to an external site. summary, there are advantages and drawbacks to each type of plan. Deciding on an insurance plan involves three main factors: 1.) affordability, or the total out-of-pocket costs (premium, deductible, copayments, coinsurance, etc), 2.) network of providers/hospitals, and 3.) prescription drug plan. Here is an Web MD article(Links to an external site. )on prescription drug plans to learn more. The cost of employer-based insurance plans has risen over the past few years. The following Kaiser Family Foundation brief discusses How affordability of employer coverage varies by family income. (Links to an external site. Specifically, take note that people with lower income actually spend higher out-of-pocket costs for health insurance. VIEW: This short video about the Affordable Care Act options and health exchange marketplaces Affordable Care Act options (Links to an external site. Cobra: (Links to an external site. )Gives temporary health insurance coverage to those who have experienced job loss or reduction in work hours. Cobra plans typically have very expensive out-of-pocket costs. Catastrophic Health Insurance: (Links to an external site. ) Catastrophic health insurance is a type of health plan that offers emergency care as well as some preventive care. These plans typically have low monthly premiums and a high deductible. READ: This Scientific American article addresses health disparities in kidney transplant care. Pay attention to how insurance status and the ability to pay for medication play a role in giving certain people access to medical care over others. For Black and Brown Kidney Patients, There Are Higher Hurdles to Care —————————————————————————————