How to Explain How the Healthcare System Works to Anyone

explain healthcare costs

The healthcare system is highly confusing at the outset, but it’s important for Americans to understand how the health care system works. Those untrained or that haven’t had to go through the process are often confused about how things are done. Yet from the inside, everything appears to make perfect sense. How then can the healthcare system be presented to make sense to absolutely anyone?
For best results, a simple approach is recommended; one that uses simple language and shies away from overly specific medical jargon. So where do we start and what are the important topics to cover?
To begin with, it’s best to explain the portal of entry system.

Explaining the Primary Care Physician

Most everyone has at least some idea about what a primary care physician is. What they may not know is their scope of practice and what their major role is in the healthcare system. The jobs of their staff may also be confusing as in many offices the patient rarely spends more than a few minutes with the actual doctor.
To begin with, it should be explained that a primary care doctor’s purpose is to determine whether the patient’s chief complaint can be solved conservatively (often with no intervention at all) or if it will require the care of a specialist.
For instance, the vast majority of colds, flus, and everyday ailments require no more than rest, fluids, and patience. The treatment in these cases is literally reassurance; the exception is when a patient presents with a compromised immune system (as seen with the very old, very young, or patients with AIDS or autoimmune conditions).
More complicated cases will often result in referral to a specialist. These might include hormonal problems such as hyperthyroidism or more serious conditions such as Triple-A (abdominal aortic aneurysm). In either situation, the best treatment is found elsewhere and the doctor’s main job is to write a referral.
It’s also helpful to understand what types of doctors can perform the role of Primary Care Physician. Nearly everyone knows that doctors with M.D. (Medical Doctor) after their name can act as Primary Care Physicians, only some realize that those with D.O. (Doctor of Osteopathy) and D.C. (Doctor of Chiropractic) after their name also act as portal of entry providers (depending on state licensing rules).

Read More: How to Pick the Best Doctor For You 

Understanding Co-Management

Some conditions may require more than one type of doctor. This is often confusing to patients because it results in multiple appointments and can be time consuming. What’s important to explain, in this case, is that doctors all have specialties.
Though an Endocrinologist specializes in the endocrine system (hormones), they actually differ to Obstetricians/Gynecologists/Urologists when it comes to sex hormones. Yet both doctors may work together to manage the same patient that has more than one type of hormonal issue.
This is also a good opportunity to explain HIPAA and medical records. To work together, doctors need to communicate with one another. That usually involves sharing records and medical notes, but it can only be done with the patient’s permission. The patient also has the right to withdraw that permission at any time.
Much of this communication is handled digitally today. This affords certain benefits to both the patient and the doctors; patients can more easily obtain their records and so can new doctors. There are certain downsides as well, particularly with large institutions (mostly hospitals) facing the rise of security breaches.

Billing and Insurance

The high costs of medical care necessitate an explanation of the fee schedules we all will inevitably have to deal with at some point. Depending on the specialty, fees can range from relatively affordable (from under $50 for a visit) to thousands of dollars. The costs can usually be broken down to a few things:

  • Demand for the doctor’s time
  • Level of specialty required
  • Cost of materials used*
  • Liability
  • Office overhead

As with any profession, the busier a doctor becomes, the more valuable their time becomes. This usually results in higher fees. But specialists also demand a higher fee, both because their training is longer and their student loans probably cost more. Additionally, their services are very exclusive and they may have no competition.
One of the harder areas to understand with regards to cost is materials used. For instance, patients might find it hard to grasp why an anti-venom costs them thousands of dollars in the US yet costs under $100 in Mexico. Part of that is because the antidote doesn’t last long and the hospital needs to cover the cost of all the expired anti-venom it throws away while it waits for someone that actually needs it.
Liability is another reason for select high costs. High insurance premiums for doctors drive up costs, but so does responsibility. When someone buys an aspirin over the counter, they’re responsible for that decision and any ill effects they might suffer. When a nurse gives a patient an aspirin, they assume the full liability of anything that happens as a result and that cost is accounted for in the aspirin (overhead is also accounted for).
Office overhead is another concern; employees all need to be paid, the lights need to stay on and equipment has to be maintained and cleaned. All of this explains why what seems like an outrageous bill to a patient is just a drop in the bucket in the cost of healthcare services.
One last area with regards to billing that might warrant an explanation is the difference in cost for customers paying with insurance vs. cash. Many offices offer a discount in exchange for cash payments because it saves the office a great deal of paperwork and time. Insurance doesn’t necessarily pay out immediately and doesn’t always pay the full amount.
Do note that in the US having a dual fee schedule for cash and insurance customers is illegal if not properly reported to insurance companies. Providing discounts or waivers of fees, however, is generally acceptable.

About the Author: Cassie is a blogger and health advocate that writes for eHealth Informer, a site that focuses on blending technology with health and wellness. As someone with a great deal of exposure to the healthcare industry, Cassie frequently finds herself writing about topics ranging from general wellness to actual industry.