The foundational system within the tiered diagnosis and treatment system is“The family doctor system,” known as the “gatekeeper” system of the healthcare delivery system and the primary care first-visit system under health insurance. Family physicians account for80%As primary care providers, they triaged the majority of patients.

In the United States, patients seeking medical care must first consult their health insurance provider—whether employer-sponsored or individually selected—to obtain a directory of in-network physicians in their area, either online or by phone.( Includes the physician's name and clinic address), choose your own family doctor. Family doctors are mainly divided into three categories: the first category is family general practitioners who treat adults and children for common and routine illnesses; the second category is internists who have undergone specialized training to manage many chronic diseases in adults; the third category is pediatricians who exclusively treat children. After selecting a family doctor, the patient can contact the doctor’s clinic by phone, and the clinic will mail a new patient registration form to the patient. The patient simply needs to complete the form and return it to the clinic. Once the doctor-patient relationship is established, the patient must inform their insurance company of the name of the chosen family doctor so that the insurer can process payments.

In addition to family physicians who provide primary care services, the second tier of physicians offering diagnostic and therapeutic services are specialists, who focus on various subspecialties such as cardiology, pulmonology, nephrology, orthopedics, endocrinology, and oncology.

After a family physician refers a patient to a specialist, the specialist maintains close communication with the family physician, exchanging information regularly and consulting as needed. Like family physicians, the vast majority of specialists operate their own private practices and have affiliations with several partner hospitals. These hospitals are utilized only when patients require complex diagnostic tests or surgical procedures. Following such interventions, patients return to the specialist’s clinic for follow-up care.

The two-way referral system refers to the transfer of patients between family physicians and specialists. Common general illnesses and chronic diseases can generally be properly managed by family physicians; however, when confronted with complex or difficult-to-diagnose conditions, such as major diseases including cancer and heart disease, family physicians will consider referring patients to specialists. In such cases, the family physician must explain the reasons for referral to the patient and obtain the patient’s consent before completing the referral form. In addition to essential basic information (such as the name of the physician requesting the referral and the patient’s name), the referral form must also include"Diagnosis/ICD” information, meaning that the family physician has made a preliminary diagnosis and assessment of the condition, and referral to a specialist is required for further evaluation and management.

Health insurance in the United States plays a significant role in the referral system. The U.S. healthcare and insurance systems are structured around community-based organizations, with the majority of treatment costs covered by the social security healthcare system and insurance providers. If patients do not go throughFor referrals from “family doctors,” bypassing them to see a specialist directly will not be reimbursed by many insurance companies.

One of the primary mechanisms by which insurance guides patients’ healthcare-seeking behavior is through price differentials, one manifestation of which is“Whether the patient was referred by their own primary care physician.” On the other hand, it depends on whether the doctors and hospitals are within the insurance-covered network. When enrolling in an insurance plan, the insurer typically provides beneficiaries with a list of participating hospitals and physicians. This list categorizes doctors and hospitals into three types: “Core Network Providers”(Core Network), "Recommended Online Resources" (preferred Network) and “non-preferred Network” (non-recommended network resources). There are significant differences in fees among doctors and hospitals across the three categories, with core network resources charging the lowest rates and non-recommended network resources charging the highest, thereby using price differentials to guide patient referrals.

[References]

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Zhang Xue,Yang Ningxi.Practices of Tiered Diagnosis and Treatment in the UK and the US and Their Implications for China[J].2015

Xi'an Jiaotong University.Tiered Diagnosis and Treatment Systems Abroad[R].2015