Organizational Systems and Quality Leadership

The U.S. healthcare industry has the largest private healthcare system while UK healthcare has one of the largest public healthcare systems globally. Increased private coverage in the U.S. healthcare system has reduced coverage for people who cannot afford private insurance. In the UK, the introduction of universal health coverage has increased healthcare access for the majority of patients. in light of this, we compare and contrast the two health systems by analyzing the UK and US healthcare systems in terms of issues such as access to coverage, the referral process, medication coverage, and financial implications to patients within both systems. 

Access between the two healthcare systems for children, people who are unemployed, and people who are retired

In the U.S., many vulnerable groups face challenges in healthcare access. According to Reinberg (2017), even though Medicaid covers people aged 65 and above, most retired people and the elderly cannot afford coverage. For instance, research carried out in 2017 indicated that over 25% of the elderly did not seek healthcare services during the previous year since they could not afford it (Reinberg, 2017). Moreover, children face similar challenges since not all children have health insurance. In particular, children from immigrant families have the least access to healthcare coverage (Leininger & Levy, 2015).A large proportion of the unemployed population does not have health coverage since it cannot afford healthcare insurance. In the UK, vulnerable groups such as the retired, the unemployed, and the elderly have high rates of healthcare access.  However, there is evidence that the elderly do not have access to quality services since the older population is less intensely investigated and treated if they suffer from chronic illnesses such as coronary heart disease and cancer (Department of Health, 2006). 

Coverage for Medications in the Two Healthcare Systems

In the U.S., coverage for medication is low since many people cannot afford healthcare insurance. Notably, even though over 90% of the population has healthcare coverage, the U.S.does not provideuniversal health coverage (Reinberg, 2017). The limited healthcare coverage reduces access to medication coverage amongvulnerable populations, such as the elderly, unemployed, and immigrant groups that cannot afford healthcare insurance. In contrast, the UK has universal health coverage and almost the entire population can access medication coverage. This is mainly because the NHS provides free treatment to the population in public healthcare facilities (Department of Health, 2006).

Requirements for a Referral to See a Specialist in the two Healthcare Systems

Referrals are pre-approvals that people with individual healthcare plans acquire from their physicians before going to see a specialist. In the U.S., people under health plans are required to select a primary care physician who will manage their health. Patients acquire referrals when the primary care physician is convinced that they need specialist help to address their health problem (Mehrotra et al., 2011). The physician is tasked with the referral process since he/she has the patient’s records and understands their ailments or conditions, which require specialist care. The first step of this process is referral decision making where the physician makes the decision to refer the patient to the specialist, and this occurs if the healthcare intervention is either not ordinarily performed by the physician or it is outside the scope of his/her work (Mehrotra et al., 2011). Once the physician determines a suitable specialist, he/she tracks the referral and ensures that the patient accesses an appointment with the specialist. Once the specialist diagnoses and treats the patient, he/she transfers the patient’s information back to the primary care physician for purposes of follow-up recommendations. 

Moreover, if patients visit physicians outside their networks or without the primary care physician’s approval, then they will likely incur the cost of the care received. In the UK, specialist approvals are requested through the general practitioner under the National Health Service coverage (National Health Service, 2019). Patients are required to seek approval for specialist care from the general practitioner they have registered with since the particular practice holds the patient’s medical records. Moreover, specialists will only see patients with a referral letter from the GP if they are under the National Health Service coverage.

Coverage for Pre-Existing Conditions in the Two Healthcare Systems

 According to the United States Department of Health and Human Services (2019), under the current law, insurance companies cannot decline coverage based on pre-existing conditions. This law was passed in 2014 and its impact is that patients do not need to pay more or lack coverage if they have pre-existing conditions. The only exception to this law is for Grandfathered plans, which are plans that people purchased for themselves or their families, before March 2010, and which have not been altered to increase costs or reduce benefits to consumers. Similarly, according to Expatica (2019), the UK healthcare system also covers pre-existing conditions through its National Health Service. These healthcare services are offered free of charge, though there may be long waiting lists since resources are stretched by free healthcare. However, for those who opt for private health insurance, pre-existing conditionsmay be covered but at a higher cost in terms of premium paid. 

Financial Implications for Patients with Regard to the Healthcare Delivery Differences between the Two Countries

The first financial implication is the growth in poverty levels within the vulnerable communities in the U.S. A large proportion of the vulnerable population cannot afford healthcare coverage and they have to cater for healthcare costs out oftheir own pockets. The increase in healthcare costs for those not covered in the U.S. has perpetuated the growth of poverty since vulnerable populations are most affected by lack of coverage (Reinberg, 2017). Funds that would otherwise cater to the personal needs of vulnerable populations are channelled towards funding healthcare, and itfuels the poverty cycle in these communities. This is in contrast to the UK where the entire population is covered under the NHS. This means that vulnerable groups are at a lesser risk of perpetuating poverty due to illnesses and high healthcare costs. 

The second effect is increased levels of unemployment, especially in the U.S., where sick people who cannot afford treatment are forced to quit employment. Due to a lack of universal care, vulnerable groups in the U.S. face high unemployment levels due to high levels of disease morbidity and mortality, which renders families jobless as they struggled to take care of the sick. Moreover, sole-breadwinners in families are also rendered jobless if they fall ill since they cannot afford healthcare coverage. In the UK where there is universal coverage, the risks of unemployment because of illness are drastically reduced due to high levels of healthcare access. 

References

Department of Health.(2006). Vulnerable groups and access to health care. Retrieved from http://www.netscc.ac.uk/hsdr/files/project/SDO_BP_08-1210-025_V01.pdf

Expatica.(2019). The National Health Service and health insurance in the UK. Retrieved from https://www.expatica.com/uk/healthcare/healthcare-basics/the-national-health-service-and-health-insurance-in-the-uk-1092057/

Leininger, L., & Levy, H. (2015).“Child Health and Access to Medical Care”.The Future children, 25(1), 65–90. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978135/

Mehrotra, A., Forrest, C. B., & Lin, C. Y. (2011). Dropping the baton: specialty referrals in the United States. The Milbank Quarterly, 89(1), 39–68. doi:10.1111/j.1468-0009.2011.00619.x

Montgomery, K. (2018). How Referrals Work With Your Health Insurance. Retrieved from https://www.verywellhealth.com/what-is-a-referral-health-insurance-1738605

National Health Service.(2019). Referrals for specialist care. Retrieved from https://www.nhs.uk/using-the-nhs/nhs-services/gps/referrals-for-specialist-care/

Reinberg, S. (2017).U.S. Seniors Struggle More to Pay for Health Care Compared to Other Countries. Retrieved from https://consumer.healthday.com/senior-citizen-information-31/senior-citizen-news-778/u-s-seniors-struggle-more-to-pay-for-health-care-compared-to-other-countries-728558.html

United States Department of Health and Human Services.(2019). Pre-Existing Conditions. Retrieved from https://www.hhs.gov/healthcare/about-the-aca/pre-existing-conditions/index.html