Health care can crudely be divided into 3 parts: Prevention, restorative/corrective, and palliative
1. Preventative Care: this is your well-child check-ups and your annual physical exams. Nothing is wrong with you yet, but you go see a doctor to optimize things so that you don't get sick, or don't get as sick. We vaccinate, do mammograms and pap smears, discuss anticipatory guidance, blood pressure screenings, etc. This typically isn't reinbursed very well because it's not considered very difficult but necessary to prevent things from getting really bad - and expensive! Another very important aspect of preventative care that is often ignored in the health-care discussion is the aspect of personal responsibility. Your doctor can lecture and encourage you about the benefits of diet and exercise, or even prescribe a necessary medication, but if YOU - the patient - do not choose to follow through with this, all preventative care will have been in vain. Doctors cannot control what their patients choose to do and what not to do.
2. Restorative/Corrective Care: This is where there's actually something wrong and something needs to be done about it. The correction can be with medicine, lifestyle changes, surgery, or some other intervention to try to restore a person to health. This is reinbursed higher depending on the difficulty of management or severity of illness. Procedures are currently reinbursed at higher rates than diagnosis and treatment with medicines.
3. Palliative Care: This is where a person's quality of life takes precidence over quantity of life. Measures are taken to keep the person as comfortable and functional as possible. This doesn't mean a person isn't treated, nor does it mean the person gets euthanized. Reinbursement isn't particularly high because major interventions typically are not performed with this option.
Payment/Insurance Options
The usual ways people pay for healthcare in this country are listed below.
1.HMO (Health maintenance organization): People join a group that manages the way care is provided in order to reduce costs. The member pays a premium and may have a copay to see a physician. Procedures and visits are scrutinized closely to assess appropriateness. All things require approval in some form, and if deemed inappropriate, the HMO may not cover the cost. There is a heirarchy in place to help manage the utilization of care. Patients go to a primary care provider first, and are referred to specialists on an as needed basis. The HMO still reviews the case for appropriateness and must approve the visit or procedure before it takes place otherwise it may not be covered. HMO's may broker deals with different hospitals or services to get a discounted rate. For this reason, you must go to an approved provider, otherwise it may not be covered. This is often a good option for those are in good health and/or seeking affordable care.
2.PPO (preferred provider organization): Similar to the HMO, this is a group that has contracted providers to obtain a more competitive rate. The member pays more in copays and possibly more in dues, but has the freedom of more providers and requires less approvals. Typically, the member can see whoever they want as long as they pay the copay. Required tests and studies are similar. It still has a review board for quality assurance and cost management, but it is generally less intrusive than in an HMO. Contracted providers are listed as "in network" and provide a greater discount. The person insured can still see out of network providers, but at a less discounted rate. PPO's are generally more expensive for an individual to buy outside of an employer benefit package.
3.Medicare/MediCAL: This is a federal/state government single payer system started in the 60's. People "pay into" the system during their working years as a percentage is deducted from their paycheck by the federal government. Once people turn 65, or if they become disabled, they are able to receive benefits from medicare. Again, there is a review committee to assure proper utilization of resources. Being that it is government run, doctors are less afraid of not getting reimbursed since it would be difficult for the government to go out of business. Also being government run, it is very large and sets the standard for reinbursement which HMO's, PPO's, and other plans follow. Each state has a program for those who fall a certain percentage below poverty level. They are then eligable for the state run health care (MediCAL in california).
4.Cash Pay: This has basically no strings attached. You get what you pay for. You can go wherever you want - or wherever you can afford. You are only limited by your resources, which can run out extremely quickly with the current cost of health care. A new type of medicine (concierge medicine) has developed in which for an additional amount of money, a physician will give you particular attention. He/she will only take on a certain number of patients to ensure you get easy access. This of course comes at a premium, but would be the easiest form of health care if you have extensive resources. On the up side, many doctors are willing to give you a discount if you pay with cash, as it lowers the cost of paperwork and processing, and is a guaranteed payment for the physician.
5.Free Clinics/charity: This is where I often worked while in residency at UCI. It was a discounted clinic with lots of grants and donations from the government, school, and community. The aim is usually to give the most effective health care with the resources you have. If it's offered and you meet the criteria (limited resources and need), you can get in line. Definitely not ideal, but better than nothing. All of my medical missions trips were all free-clinics.
MD vs DO:
1.Allopaths: These are your traditional "MD's." They are trained in western medicine where the emphasis is on the scientific method - or scientifically testable hypotheses. They must complete a residency in their specific fields ranging from 3 to 5 years. Afterwards, they can go on to a fellowship for more specialized training for an additional 3+ years. They are required to take USMLE "Step 1" basic sciences exam first year of med school, "Step 2 CK" clinical knowledge exam second year of med school, and "Step 2 CS" clinical skills (patient interaction) exam second year of med school. "Step 3" (clinical knowledge again) is taken during the first year of residency.
2.Osteopaths: They are also medical doctors but "D.O.'s" encorporate adjustments and body manipulation into their practice. It is generally more holistic in its approach to health care. It is also a 4 year medical school, with similar residency requirements. There are specific osteopathic residencies, but to go to an allopathic residency instead, the doctor must take all USMLE "step" exams in addition to the osteopathic "COMLEX." Both osteopaths and allopaths must take licensure exams to become board certified in their specialty. Admission criteria has generally been a little lower in regards to GPA and MCAT scores, but the attempt is to obtain more "well rounded" individuals with a broader range of life experiences.
Types of Practitioners
1.Generalists: Also known as primary care provider (PCP), or general practitioner (GP), these are your general pediatricians, general internists, family doctors, etc. They handle non advanced medical illnesses routinely, preventative care, and manage the overall care of the patient. When medical illnesses become advanced, the patient is referred to a specialist. At that time, the generalist is still involved to help coordinate care between the specialists. They are generally easier to get appointments with, and cost less money. They also are paid less than specialists. This is typically the doctor the patient develops a long standing relationship with. The managed care/insurance companies use generalists as "gatekeepers" who act as filters to keep the higher paid specialists from being bombarded with patients.
2.Specialists: These physicians have gone through fellowship training to become board certified in their area of expertise. They focus on that specific area almost entirely. They know a particular organ system very well, but may not pay as much attention to other organ systems. For example, a heart doctor (cardiologist) manages heart stuff, but may not pay as much attention to the kidneys. If the patient has both a cardiologist and a nephrologist (kidney doctor), the primary care doctor will maintain the big picture to ensure the kidneys, heart, and other organ systems are taken care of.
3.Non Physicians: These are physical therapists, occupational therapists, speech pathologists, podiatrists, nurse anesthetists, physicians assistants, and nurse practitioners (to name a few). They do not go through as much schooling as physicians, but handle the common diseases very well. They are utilized primarily to expedite care, extend care to a greater number of people, and control costs. They all may work under the supervision of a physician to prescribe medicine or render other care.
Medical Philosophies1.Evidence Based Medicine: this is the idea that the practice of medicine is based upon scientifically reproducible non-biased evidence. There are many different statistical analyses that are done to ensure the patient is getting care based upon things proven to be effective. The example of our most reliable statistical analysis is the double blind control trial. In this experiment, two groups are formed at random. Both groups and the experimenter do not know which group they are in. One group gets the drug or procedure, and one group doesn't. Extraneous factors which may influence the results (confounders) are controlled (held constant) to not influence results. For example, if you're doing an experiment on whether or not a diabetes medicine works, you would want the groups both to have similar lifestyles. If one group is comprised of people who eats sweets, and the other group comprised of vegetarians, this could influence your results. To control for this, you can either completely randomize the group selection so it probably will even out on both sides, or you can only get people in the study who are vegetarians, eat sweets, do neither, or do both. Ideally, you would obtain a very large, diverse group which is representative of the population you want to treat, and then base your patient's treatment on the results of the study.
2.Apprenticeship/Practice Based Medicine: When it is impossible to do tests on humans because of ethics or other reasons, or if studies have not been performed on the treatment in question, it is also possible to base treatment on experience gathered from previous physicians. For example, there haven't been studies showing what to do if you are in the operating room perforing spinal surgery and accidently cut a nerve. At that point, a more senior surgeon would say what his experience has told him to repair the mishap. Practice based medicine is valuable because the human body is not a machine, and a doctor with a lot of experience would have seen patients react differently to different treatments or situations. Additionally, you just can't test every patient for every possible disease.
3.Standard of care: This is the term for accepted/expected practice drawn as a consensus from the majority of physicians.
4.Defensive medicine: This is the term used for practice influenced to protect against possible litigation.
5.Malpractice: This is a legal term for failing to act in accordance with standard of care which directly results in damages to the patient.
Medication Options1.Prescription medications: These are medications monitored by the FDA and approved for use when determined appropriate by a physician. They may be brand name, where they're still on patent and cost more, or generic, where the patent has expired and they are now available at a cheaper cost. The active ingredients are the same and must meet FDA standards of safety and efficacy. Insurance companies cover varying percentages of brand names and generics.
2.Nutritional Supplements: These are substances which are not regulated by the FDA, do not have to meet standards of dosing, and are not allowed by law to be advertised as treatment for a condition. There are ways the companies get around this with their wording. They often use the term "all natural" but that does not mean "safe." Both prescription medications and supplements are billion dollar industries. There usually has not been testing for efficacy or even safety, but many patients report improvement of symptoms while on these substances. Some studies show nearly 50% of Americans take supplements. However, just as with prescription drugs, over use of nutritional supplements (even vitamins) can be detrimental to a person's health.
3.Over the counter (OTC): These are medications which have been approved for use without a prescription. This does not mean safe. All medications have side effects.
4. Behind the counter: These medications are available for purchase without a prescription, but are held behind the counter because of potential for abuse or for safety reasons (eg pseudoephedrine).
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