Behavioral Science

Health Care in the United States 193
What are the two primary health plans
offered by private health-care insurers?
Which type of health-care insurance
plan has high premiums and does not
impose restrictions on provider’s
choice?
What are the primary characteristics
of a health-care managed-care plan?
What are the types of health-care
managed-care plans?
What is a health maintenance
organization (HMO)?
What is meant by a physician being a
“gatekeeper”?
What are preferred provider
organizations (PPOs)?
1. Fee-for-service plans
2. Managed-care plan
Fee-for-service plans
Low premiums
Restrictions on provider’s choice
Health maintenance organization
(HMO)
Preferred provider organizations (PPOs)
Point of service (POS)
An HMO has arrangements with
health-care providers to form a
“network.” The providers give the
HMO a discounted rate in exchange for
receiving health plan referrals. Members
may only see physicians in this network,
otherwise the costs are not be covered
by the plan. Members select a primary
care physician (PCP), often called a
“gatekeeper,” who provides, arranges,
coordinates, and authorizes all aspects
of the member’s health care.
Often the primary care physician (PCP)
in an HMO plan must approve specialist
and ancillary service referrals as well as
coordinate the member’s care.
PPOs are similar to HMOs in that they
have arrangements with a “provider
network.” Unlike an HMO, members
may choose a doctor outside of this
network, but their coverage will be at a
reduced rate (ie, out-of-pocket expenses
are higher).
HEALTH-CARE COSTS
How does the United States compare
with other countries in terms of
health-care spending?
The United States spends significantly
more per capita and as a percentage
of GDP on health care than any other
nation.