Medical Care in the USA

If you are new to this country, you may have discovered that our medical care is slightly (or even greatly) different from medical care in your native country. In the United States, we do not have socialized medicine or national health insurance. Instead, in order to obtain medical care, you must either have health insurance or pay for the medical care directly yourself.

Doctors

Before discussing insurance, we should discuss how our health care system is set up. Most doctors in America must go to four years of college, and then pass tests and show excellent qualifications before being accepted at a medical school. In medical school, they study for four more years after graduating from college.

They also do clinical studies in a hospital, including a year of internship, then several years as a resident, learning under the supervision of other doctors. They may decide to specialize in a branch of medicine, such as cardiology or gynecology, or they may choose to become a family practice doctor or an internal medicine doctor. Many medical doctors practice at hospitals, and at clinics where patients are seen outpatient. They may choose to go into private practice, where they will see patients at their own office (which may be shared with other doctors in a group practice). But most doctors also have admitting privileges at a local hospital they are affiliated with, and can help admit a very ill patient.

Nurses and Medical Assistants

Nurses and medical assistants help doctors provide health care in hospitals, clinics, and private offices. These providers must be licensed by going to school (from two to four years for nurses depending on the type of license or degree) and pass a licensing exam. They will often see a patient when they first come in, and will ask questions and obtain a health history. They will also check vital signs (blood pressure, pulse, temperature, and breathing rate) and will alert the doctor of any unusual symptoms or problems that they notice. They will help with drawing blood for laboratory tests if necessary, and with minor procedures such as inserting an intravenous line. They will also often assist the doctor with certain procedures, setting up equipment and sterile trays, for example. And if a person is inpatient, the nurses and medical assistants will administer you most of the treatments that have been ordered by a physician, as well as assisting you with meals and personal care.

Emergency Rooms

Most hospitals have an Emergency room which will quickly admit very ill people for emergency medical care. In almost all communities, dialing 911 will bring an ambulance, which can transport you to the Emergency room (there is a fee for this transport which is usually billed to your insurance). Emergency medical care is usually quite expensive, and should be reserved for true emergencies.

Paramedics, EMTs, and sometimes nurses who are all highly trained in emergency medical care will come with the ambulance, and begin to administer emergency care en route to the closest medical center which can provide adequate care. For instance, a burn victim may be routed to the closest hospital that has a burn unit, while a young child may be taken to the closest Children's hospital. In rural communities, a person with severe trauma or illness may be taken to the Emergency room and stabilized, then taken by Life Flight (a helicopter than contains emergency medical equipment and staff) to a larger medical center. Life flight may also transport victims of automobile accidents in areas where ambulance care would take too long to reach.

Emergi-care or acute care clinics are clinics that will quickly see people who are ill, but not quite ill enough for an emergency room. If a person does not have a family physician, they can also receive acute care at these facilities. You usually must pay the complete cost of the care at the clinic at the time that services are received, unless your insurance has coverage.

Clinics

Some of the larger teaching hospitals and county hospitals will have clinics that provide health care at a reduced rate. Some rural areas will also have health clinics that provide immunizations for families who cannot afford private care, or who don't have insurance. Clinics may be general care, family practice practices with primary care physicians, or specialty clinics (such as cardiology, endocrinology, or prenatal care clinics). Often interns and residents will do a rotation through a clinic for several months, and are supervised by attending doctors with experience.

Dental and eye care clinics may also be affiliated with teaching hospitals and medical/dental schools in many cities, and can a more affordable method of obtaining dental and eye care for the person who does not have insurance, or whose insurance does not cover these services.

Standards of Care

The standards of care at hospitals, clinics, and organizations are very high in the United States. Government regulations insure that all personnel are licensed and qualified, and that the clinic and/or hospital meets standards for quality. Licensing organizations such as JCAHO (Joint Commission on Accreditation of Health Care Organizations) will also visit hospitals. Their accreditation and rating are dependent on how well they meet these universal standards for providing care.

Preventative Health Care

The prevention of illnesses and communicable diseases is important in the United States. For this reason, regular immunization of children is mandated by law, and an up-to-date immunization record is required at public schools when a child registers. These immunizations can be given at intervals during "well child" visits, and can be obtained at county clinics, local health departments, or at your child's physician's office.

Understanding Health Insurance

Many employers will provide health insurance as a benefit of the job to their employees, but not all do. Some smaller employers do not provide insurance because it is expensive, and they can't afford it. But federal law requires any employer with 25 or more employees to offer the chance to enroll in an insurance plan such as a HMO.

If your work provides insurance, it is a type known as group insurance. Normally the employer pays part of the cost, and you pay the rest of the monthly premium, which is deducted from your paycheck if you choose to have insurance. Normally insurance works this way: you pay a monthly premium on it, as insurance against becoming ill. If you become ill, then your insurance provider will pay part of the cost of your medical care and/or hospitalization. You will probably have to pay a certain amount yourself (known as a "deductible" which will vary with different plans), and you may be expected to pay a certain percentage of the cost yourself. For example, many plans pay 80% of the costs of medical care, while the person covered is expected to pay 20%. You can also often purchase what is known as supplemental insurance, which will help to pay for the remaining 120 of the costs, or the costs not covered by your primary insurance.

Dependent Coverage

Some people obtain insurance by being covered by the insurance policy that their spouse has. They are listed as dependents on their spouse's policy, and the entire family can be covered in this manner. But the monthly premium rates also are higher with an increased number of dependents covered.

COBRA Coverage

It is important to realize that if you leave your job, you will probably also lose your insurance coverage unless you choose to continue the premium yourself (which can be costly). Under the federal COBRA laws, an employer of 20 or more employees must allow a former employee to continue paying for insurance for up to 18 months after leaving their place of employment, but the premium will be higher after leaving the workplace. If you were a dependent covered by your spouse's insurance, and you become widowed or divorced, you can still be covered for a period of time under COBRA as well.

Sometimes if your work does not provide insurance, you can get group rates by joining certain organizations (such as the national organization of small business owners), through a union, or through community groups. You can also choose to buy private insurance, but premiums are usually higher and there is less coverage than with a group policy.

Understand your Policy

Whether you are covered by group insurance at your work, or buy private insurance, it is important to understand how your particular insurance coverage works. Be aware of:

• What costs it pays for (and what isn't covered). This is extremely important, since some insurance policies are very limited in what they will cover, while others have broader coverage. And a basic plan will have much different coverage than a comprehensive or major medical plan.
• Be aware of what the copay or deductible is for items such as medications, office or clinic visits, routine procedures, and how much your insurance will cover for inpatient hospital stays and laboratory tests. Be aware that some insurance plans do not cover medications, for example (or for only a small percentage of their cost), and others may be very limited in their coverage for conditions such as outpatient mental health treatment. You may want to contact an insurance agent and have his or her help with looking at the benefits and costs of different types of coverage.

About Managed Care

Most insurance plans operate under a "managed care" system. This is a way of containing medical costs, and to help ensure that only necessary procedures are done. This term may mean that before seeing a doctor or being admitted to a hospital, your insurance company must be contacted for pre-authorization or precertification (or else it won't get covered). Certain procedures or specialist visits must also be pre-authorized under many policies, and the concept of "reasonable costs" means that certain diagnoses will have what are termed a "reasonable cost" that your insurance company will pay for that diagnosis. If your hospital or physician charge above this, you may be responsible in some cases for the difference.

Different Types of Insurance Coverage

Fee for service plans

This type of insurance will cover most providers and hospitals and pays fees for services that you receive from them. You will have a deductible, or yearly amount that you must pay before the insurance company starts paying for services (each year, the deductible renews and you must pay it again). This deductible can vary from a couple of hundred dollars to several thousand, depending on the policy. Once the deductible is met, the insurance company pays part of the costs of covered (remember to check what is covered!) medical services, and you pay the rest. A typical split is 80% paid by the insurance, while you pay 20%.

When you receive medical care, you will be asked to fill out forms and send them to your insurance provider for reimbursement (your doctor's office may fill them out for you in some cases). Your plan may also have a limit to how much you are required to pay in a year's time in total medical expenses. This may vary from $1000 to $5000 depending on the policy's maximum for out of pocket expenses.

Health Maintenance Organization (HMO)

This type of health plan is prepaid with a monthly premium. It provides comprehensive coverage, which means that it covers all medical costs for doctor visits, hospitalizations, lab tests, emergency care, preventive health care such as immunizations, and other items provided by medical providers who contract with the HMO. All medical care must be provided by doctors and hospitals which contract with the HMO (the only exception is medical emergencies, when you may be taken to the closest medical facility that provides treatment. In this case, the HMO will pay).

Kaiser Permanente in California is an example of a large HMO: it has its own doctors, medical care providers, clinics, and hospitals, and anyone with Kaiser coverage must go to a Kaiser (or Kaiser contracted) facility or doctor. When you sign up for the HMO, they will give you a book with a list of approved providers in your area, and will ask you to choose a family physician from the list, or they assign one to you. This person becomes your primary care physician who takes care of your routine health care needs. If you need a specialist, your primary care physician must first refer you to one.

Sometimes you can self refer yourself to an outside specialist if your HMO has point of service (POS) coverage. If you see a doctor who is out of network, you will be fully covered if your primary care physician referred you, or you may receive partial coverage (such as 50%) if you self -referred. But if your HMO does not have this option, then if you self refer you will have to pay the full cost of the visit.

The copay is usually minimal for routine visits. Once you register with an HMO, you also do not have to fill out paperwork each time you receive medical care. Instead, they will issue you a card with an identification number on it, and during each visit you present the card. Normally, clinics are quite busy at HMOs, so it is good to make appointments quite awhile ahead of time if you need a special hour (early or late), and you can expect a wait once you arrive.

Preferred Provider Organization (PPO)

A preferred provider organization is a type of compromise between a fee for service plan and an HMO. When you sign up for this type of insurance, you will be given a list of "preferred providers" or "network providers". When you visit one of these doctors, most or all of your medical costs will be covered by your health insurance. And like an HMO, you present a card when seeing a preferred provider (instead of filling out paperwork each time). You will also be asked to choose a primary physician from the approved list of preferred providers, and to see him or her for routine visits. If you need a specialist, this primary care physician must be the one to refer you if you want full or almost full coverage.

But you can also see a doctor who is not part of the preferred list (an "out of network" doctor). Normally you will have to pay a higher percentage of the cost of the visit (such as 50% or 40%) if you are seeing an out of network provider. When seeing an out of network provider, you must also fill out paperwork for each visit, similar to that which is filled out with a fee for service plan.

Other Things You Should Know About Health Insurance

Sometimes you may be covered by more than one insurance plan. For example, you may be listed as a dependent on your spouse's insurance, but also have your own insurance from your work. The insurance that pays the largest percentage of the medical bill is considered your primary insurance, and the other is your secondary insurance. Most insurance plans require a coordination of benefits, where both companies are aware of what the other is covering, and the total reimbursement for any medical procedure by both companies together cannot be more than 100 percent.

While your health insurance may cover medical care, it may or may not cover such items as dental care or eye care (including eye exams or glasses). It is important to find out whether these things are covered. Often an employer will provide a supplemental dental policy, although this also has a monthly premium which is deducted from your paycheck if you sign up for it. Preventive dental care (such as regular dentist visits, daily cleaning and flossing) can help prevent dental problems such as gum disease or decayed teeth. A doctor of dental scientist can do minor oral surgery and root canals, as well as fill cavities, perform dental x-rays, and provide care for your teeth with the help of dental hygienists (specially trained and licensed assistants).

If you have a pre-existing health condition when you sign up for insurance (such as diabetes, hypertension, or other chronic diseases) in some cases, the insurance provider may choose to deny coverage, or you may have to pay a higher rate to have coverage. In some states, mandatory state sponsored insurance is available even if you have a pre-existing condition, although the monthly premiums can be quite high.

Government Sponsored Health Care Programs

In general, this is only available to the elderly or the disabled. If a person is disabled and unable to work, or is over age 65, they will qualify for Medicare. The poor may obtain coverage through Medicaid (Medical in California), which is federally mandated but is administered jointly with the individual states.