There
are six major entities,
- Regulators and Policy Makers
- Payers
- Advocacy Organizations
- Providers
- Suppliers
- Consumers
1)
Regulators and policy makers
At the top of the pyramid, the federal government sets the
tone for the entire system. Many other entities have been formed over the years
in response to the need for control over various areas of the healthcare
industry. Today, the most influential regulators include the U.S. Department of
Health and Human Services (HHS), the Centers for Medicare and Medicaid Services
(CMS), the Food and Drug Administration (FDA), and the Centers for Disease
Control and Prevention (CDC). These entities have been charged to interpret,
implement, and ensure compliance with the current laws of the United States
that affect and govern the healthcare industry. The scope of regulatory
influence of these entities is determined by the laws they enforce. At the
state level, state legislatures, state and local governments, health departments,
state medical boards, and state insurance commissions also play significant
roles while functioning within federal regulations. Nevertheless, state
governments have been successful in introducing unprecedented moves that go
beyond federal mandates for healthcare policy; for example, Massachusetts Was
able to mandate health insurance coverage for all its citizens in 2006.
2) Payers
Financing in the U.S. healthcare system can be broken down
into payments made by the public sector (the federal government, state and
local governments), the private sector (private insurers and businesses), and
the consumer (out-of-pocket expenses and self-pay). Public funding of the U.S.
healthcare system includes federal sources, such as Medicare and Medicaid programs,
the Veterans Administration, and the U.S. Department of Defense, and state and local
programs, such as Medicaid and state and local hospitals. Private funding includes
out-of-pocket expenditure, private insurance, and philanthropy. As can be
inferred from this list, many of these payers have other capacities and exert substantial
influence in other areas of the U.S. healthcare system through policy making
(e.g., CMS) or through advocacy groups and lobbying (e.g., private insurance
companies).
3)
Advocacy organizations
This category encompasses organized efforts of smaller
entities in the healthcare system around a common interest that is frequently
self-serving. Examples of these groups include the American Medical Association
(AMA), the American Society of Clinical Oncology (ASCO), the American Hospital
Association (AHA), the American Nurses Association (ANA), America’s Health
Insurance Plans (AHIP), and the National Patient Advocate Foundation (NPAF).
4)
Providers
This category includes all individuals and organizations that
provide a healthcare service to the consumer. As such, it includes health
practitioners, hospitals, nursing homes, and other similar entities. Although
health professionals are central to the specific entity that actually provides
care, hospitals, in particular, offer the environment in which care can be
provided and are compensated by payers for the services provided. It is in the
hospital setting that a substantial portion of healthcare resources are
consumed. Individual practitioners, practice groups, general hospitals,
specialty hospitals, ambulatory facilities (surgery, imaging, etc.), and
integrated healthcare systems are also examples of providers.
5)
Suppliers
This category includes pharmaceutical companies and medical
equipment companies. These entities have grown to be a significant part of the
healthcare system and are in fact considered industries of their own. Although
suppliers are integral to the healthcare system, the nature of their business
is different. Like private insurance companies, most of these organizations are
for-profit and publicly traded companies and exist in a different competitive
environment. Unlike the payer category, the amount of not-for-profit activity
in this category is small.
6)
Consumers
People, whether sick or healthy, are consumers of care. In
the industrialized world, one would be hard pressed to find anyone who has
never received any care within a healthcare system. Consumers of healthcare
services are somewhat different from consumers in other sectors of the economy.
Two primary differences are
(1) healthcare consumers often have to depend on the advice of a physician in making a health services “consumption” decision, and
(2) in most instances, the consumer is unaware of the full costs of his or her choice because of the intermediary function of payers even though there may be a significant out-of-pocket
Two primary differences are
(1) healthcare consumers often have to depend on the advice of a physician in making a health services “consumption” decision, and
(2) in most instances, the consumer is unaware of the full costs of his or her choice because of the intermediary function of payers even though there may be a significant out-of-pocket
component of the full cost.
To know more about financial spending refers US Healthcare Financial Spending Across all Entities
To know more about financial spending refers US Healthcare Financial Spending Across all Entities
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