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Health Reimbursement Systems in the US

The modern healthcare sector remains one of the most important aspects of the evolution of our society. The fact is that the health of the nation depends on the efficient functioning of the given sphere and its ability to provide care to all individuals who have a need for it. However, the peculiarities of modern healthcare, medicines, technologies used to examine patients and diagnose illnesses, precondition the extremely high price for certain services. In this regard, the question of reimbursement becomes extremely topical for the healthcare sector, as there are numerous attempts to improve the existing approach and attain lower prices along with better results. Anyhow, the current system peculiar to the USA could be considered extremely complex as there are numerous mechanisms for payments that are used to support the development of the sphere.

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At the moment, the USA has an advanced but expensive healthcare system that demands about $3 trillion annually (“Healthcare reimbursement & changing rules,” n.d.). For this reason, there is a unique need for a specific model of financing. First of all, the government acts as the main sponsor to the system creating governmental insurance programs and devoting funds to promote the development of care delivery and to make the most important health services more affordable (“Healthcare reimbursement & changing rules,” n.d.). Moreover, there are also private insurance programs that are very popular in the USA. Great insurance companies devote funds to healthcare as it is one of their main spheres of activity. Finally, there is the third source, which is private investments (“Hospital health care payment mechanisms,” n.d.). People pay themselves for services they are going to use. In general, these three sources create the fund needed to pay care providers and support the functioning of the healthcare sector.

That is why care providers in the USA become dependent on the above-mentioned mechanisms of financing. The given system is imperfect; however, there is still no other alternative for care providers to obtain money. For this reason, the following patterns could be used. For instance, in case a patient has medical insurance, provided care will be paid by the company that cooperates with an individual and guarantees that in case some medical problem appears, funds will be transferred to a medical care unit to pay for the needed treatment. Moreover, when a patient falls into a certain category that gives a right to use medical benefits, all spending should be covered by the government that is responsible for the introduction of such special conditions for people with different problems (“Hospital health care payment mechanisms,” n.d.). Finally, a person might pay by himself/herself; however, it is the rarest way to pay care providers as traditionally, the sum is great.

The complexity of the system also preconditioned the appearance of numerous attempts to regulate health care costs and assure that they are distributed in a fair way, or that the main spending decreases. Thus, access to health services could be decreased or limited to guarantee that less money will be spent. Traditionally, insurance companies tend to refuse patients who are likely to have many visits to the hospital (Trivedi, n.d.). Moreover. Unnecessary care could also be eliminated to assure that funds will not be spent in vain. For instance, any procedure that does not improve health or does not help to discover a problem could be removed to save costs (Trivedi, n.d.). Finally, the costs spent on healthcare could be reduced by improving the health of the nation. In such a case, individuals will need fewer services, and additional payment will not be needed.

Besides, the above-mentioned mechanisms should also be taken into account by nurse managers who work with patients. The fact is that, very often, the question of payment and reimbursement comes along with ethical concerns. In case a patient is not able to afford treatment, he/she could be deprived of an opportunity to obtain care. For this reason, an ethical dilemma appears (“Healthcare reimbursement & changing rules,” n.d.). Thus, a nurse manager always works close to patients aligning cooperation with them and determining their main needs. At the same time, this specialist is also responsible for determining the payment model that could be chosen to pay caregivers and guarantee that treatment will be initiated. In this regard, they should be ready to consider the most appropriate way of reimbursement and whether a patient could use it or not. The given task is very important for the functioning of any healthcare unit as it guarantees that funds needed for its further development will be obtained.

Altogether, the current system used to finance the healthcare sector in the USA is extremely complex. There are several different sources that are used to pay caregivers and support the evolution of the sphere. Government programs, insurance, and personal payments become the most important mechanisms that are used in healthcare nowadays. However, costs remain too high, and the need for their reduction is obvious. That is why there are numerous attempts to control them and reconsider the current approach used in healthcare to pay for different services.


Healthcare reimbursement & changing rules. (n.d.)

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Hospital health care payment mechanisms. (n.d.)

Trivedi, A. (n.d.). Controlling health care costs.

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