This article examines the overall organization of services and delivery of health care in the United States. Health maintenance organization, fee-for-service, preferred provider organizations, and the Veterans Health Administration are discussed, with a focus on structure, outcomes, and areas for improvement. An overview of wait times, malpractice, telemedicine, and the growing population of physician extenders in dermatology is also provided.
This article examines the overall organization of services and delivery of health care in the United States. Health maintenance organization (HMO), fee-for-service (FFS), preferred provider organizations (PPOs), and the Veterans Health Administration (VHA) are discussed, with a focus on structure, outcomes, and areas for improvement. An overview of wait times, malpractice, telemedicine, and the growing population of physician extenders in dermatology is also provided.
HMO
An HMO is a type of managed care plan in which a network of designated health care providers (eg, physicians, nurse practitioners [NPs], therapists) is available to enrollees. Under the HMO model, there is a gatekeeper (GA), usually aprimary care physician (PCP), whom the patient must first see to obtain a referral to a specialist. By contracting with a specific network of health care providers, and by emphasizing preventive care, HMOs are able to keep costs low. However, this cost cutting may also lead to certain disadvantages, including restricted access to specialists within the HMO network, and lack of coverage for procedures that the HMO may deem unnecessary. Under the Medicare HMO plan (also known as Medicare Advantage), patients are enrolled in traditional Medicare A and B, along with an HMO that offers extra services not covered by Medicare alone, such as prescription drugs, eyeglasses, and dental care.
FFS
In an FFS system, health care services are unbundled and paid for separately. The advantage of an FFS model is that patients have the freedom and flexibility to choose any physician and hospital, not just those restricted to a certain network. The trade-off for this autonomy is that patients often have to pay higher copayments and deductibles. A copayment is a set fee, usually in the range of $20 to $40, which patients pay per visit to the physician. The amount of the copayment may differ between physicians in primary care and specialty settings. A deductible differs in that the amount paid is usually a percentage of the total costs for a service. The insurance then covers the remainder of the costs. Depending on variations in insurance policies and treatment plans, patients may be required to pay copayments, deductibles, or both. Physicians under the FFS system receive payment for each type of service rendered, such as an office visit, test, procedure, or other health care services. Because a GA is not required under FFS, patients typically have direct access to specialists. Medicare FFS is also known as traditional Medicare, in which patients are enrolled in Medicare A and B, and pay higher deductibles and premiums to gain access to a wider network of physicians compared with Medicare HMO ( Fig. 1 ).
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