US health care system overview 1

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US health care system overview 1

  1. 1. Chapter 1 Major Characteristics of U.S. Health Care Delivery
  2. 2. Introduction <ul><li>The United States has a unique system of health care delivery. </li></ul><ul><li>The US health care delivery system is complex and massive. </li></ul>
  3. 3. Introduction <ul><li>“ Health care delivery” and “health services delivery” </li></ul><ul><ul><li>Can have slightly different meanings,but in a broad sense, both terms refer to the: </li></ul></ul><ul><ul><ul><li>major components of the system </li></ul></ul></ul><ul><ul><ul><li>processes that enable people to receive health care. </li></ul></ul></ul><ul><ul><ul><li>provision of health care services to patients. </li></ul></ul></ul>
  4. 4. Introduction <ul><li>In contrast to the United States, </li></ul><ul><ul><li>most developed countries have national health insurance programs </li></ul></ul><ul><ul><ul><li>referred to as “universal access” </li></ul></ul></ul><ul><ul><ul><ul><li>provide routine and basic health care </li></ul></ul></ul></ul><ul><ul><ul><ul><li>run by the government and financed through general taxes. </li></ul></ul></ul></ul><ul><ul><li>All Americans are not “entitled” to routine and basic health care services. </li></ul></ul>
  5. 5. Introduction <ul><li>187.4 million Americans have private health insurance coverage, </li></ul><ul><ul><ul><li>35.2 million Medicare beneficiaries, and </li></ul></ul></ul><ul><ul><ul><li>31.5 million Medicaid recipients. </li></ul></ul></ul><ul><li>Health insurance can be bought from: </li></ul><ul><ul><li>1,000 health insurance companies </li></ul></ul><ul><ul><li>70 BlueCross/BlueShield plans </li></ul></ul><ul><li>The managed care sector includes approximately: </li></ul><ul><ul><li>540 licensed health maintenance organizations (HMOs) </li></ul></ul><ul><ul><li>925 preferred provider organizations (PPOs) </li></ul></ul>
  6. 6. Subsystems of US Health Care Delivery <ul><li>Managed Care </li></ul><ul><li>Military </li></ul><ul><li>Vulnerable Populations </li></ul><ul><li>Integrated Delivery </li></ul>
  7. 7. <ul><li>Managed Care </li></ul><ul><ul><li>A system of health care delivery that: </li></ul></ul><ul><ul><ul><li>1) seeks to achieve efficiency by integrating the basic functions of healthcare delivery </li></ul></ul></ul><ul><ul><ul><li>2) employs mechanisms to control (manage) utilization of medical services </li></ul></ul></ul><ul><ul><ul><li>3) determines the price at which the services are purchased and how much the providers get paid. </li></ul></ul></ul>Subsystems of US Health Care Delivery
  8. 8. <ul><li>Managed Care </li></ul><ul><ul><li>Is the most dominant health care delivery system in the United States and available to most Americans. </li></ul></ul><ul><ul><li>Employers and government are the primary financiers of managed care </li></ul></ul><ul><ul><li>An MCO functions like </li></ul></ul><ul><ul><ul><ul><li>an insurance company </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>it promises to provide health care services contracted under the health plan to the enrollees of the plan. </li></ul></ul></ul></ul></ul>Subsystems of US Health Care Delivery
  9. 9. <ul><li>Managed Care </li></ul><ul><ul><li>Enrollee refers to: </li></ul></ul><ul><ul><ul><li>a member </li></ul></ul></ul><ul><ul><ul><li>an individual covered under the plan </li></ul></ul></ul><ul><ul><li>Health plan: </li></ul></ul><ul><ul><ul><li>a contractual arrangement between the MCO and the enrollee </li></ul></ul></ul><ul><ul><ul><ul><li>includes a list of covered health services to which enrollees are entitled </li></ul></ul></ul></ul><ul><ul><ul><li>uses selected providers </li></ul></ul></ul><ul><ul><ul><ul><li>usually primary care, general practioners </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>--the “gatekeepers” </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Look at Figure 1.1, page 5 </li></ul></ul></ul></ul>Subsystems of US Health Care Delivery
  10. 10. Subsystems of US Health Care Delivery <ul><li>Military </li></ul><ul><ul><li>The military medical care system is available free of charge to: </li></ul></ul><ul><ul><ul><li>active duty military personnel of the U.S. Army, Navy, Air Force, and Coast Guard, </li></ul></ul></ul><ul><ul><ul><li>certain uniformed nonmilitary services such as </li></ul></ul></ul><ul><ul><ul><ul><li>the Public Health Services and </li></ul></ul></ul></ul><ul><ul><ul><ul><li>the National Oceanographic and Atmospheric Association (NOAA) </li></ul></ul></ul></ul>
  11. 11. Subsystems of US Health Care Delivery <ul><li>Military </li></ul><ul><ul><li>The military medical care system is </li></ul></ul><ul><ul><ul><li>well-organized </li></ul></ul></ul><ul><ul><ul><li>highly integrated </li></ul></ul></ul><ul><ul><ul><li>comprehensive </li></ul></ul></ul><ul><ul><ul><ul><li>covers preventative care </li></ul></ul></ul></ul>
  12. 12. Subsystems of US Health Care Delivery <ul><li>Military </li></ul><ul><ul><li>TRICARE </li></ul></ul><ul><ul><ul><li>Financed by the military, and covers families, dependents or retired military </li></ul></ul></ul>
  13. 13. Subsystems of US Health Care Delivery <ul><li>Military </li></ul><ul><li>The VA health care system </li></ul><ul><ul><li>available to retired veterans </li></ul></ul><ul><ul><li>focuses on </li></ul></ul><ul><ul><ul><li>hospital, mental health and long-term care </li></ul></ul></ul><ul><ul><li>Is one of the largest and oldest (1946) organized health systems in the world </li></ul></ul>
  14. 14. Subsystems of US Health Care Delivery <ul><li>Military </li></ul><ul><li>The mission of the VA health care system: </li></ul><ul><ul><li>Provide medial care, education and training, research, contingency support and emergency management for the Department of Defense medical care system. </li></ul></ul>
  15. 15. Subsystems of US Health Care Delivery <ul><li>Military </li></ul><ul><li>The VA health care system has: </li></ul><ul><ul><ul><li>over 1,100 sites </li></ul></ul></ul><ul><ul><ul><li>172 hospitals </li></ul></ul></ul><ul><ul><ul><li>206 counseling centers </li></ul></ul></ul><ul><ul><ul><li>40 residential care facilities </li></ul></ul></ul><ul><ul><ul><li>73 home health programs, and </li></ul></ul></ul><ul><ul><ul><li>provides care to 3.6 million </li></ul></ul></ul>
  16. 16. Subsystems of US Health Care Delivery <ul><li>Military </li></ul><ul><li>The VA: </li></ul><ul><ul><li>Budgets over $20 billion </li></ul></ul><ul><ul><li>Employs over 182,000 </li></ul></ul><ul><ul><li>Affiliates with </li></ul></ul><ul><ul><ul><li>13,000 physicians </li></ul></ul></ul><ul><ul><ul><li>53,000 nurses </li></ul></ul></ul><ul><ul><ul><li>3,500 pharmacists </li></ul></ul></ul>
  17. 17. Subsystems of US Health Care Delivery <ul><li>Military </li></ul><ul><li>The VA is: </li></ul><ul><ul><li>organized into 22 geographically-distributed Veterans Integrated Service Networks (VISN) </li></ul></ul><ul><ul><ul><ul><li>Each VISN </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>coordinates its own services </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>receives federal funds </li></ul></ul></ul></ul></ul>
  18. 18. Subsystems of US Health Care Delivery <ul><li>Vulnerable Populations </li></ul><ul><ul><li>Particularly the poor, uninsured, minorities and immigrants </li></ul></ul><ul><ul><ul><li>live in disadvantaged communities and receive care from “safety net” providers. </li></ul></ul></ul>
  19. 19. Subsystems of US Health Care Delivery <ul><li>Vulnerable Populations </li></ul><ul><ul><li>Safety nets are not secure </li></ul></ul><ul><ul><ul><li>Provider type and availability vary </li></ul></ul></ul><ul><ul><ul><li>Some individuals forego care and seek hospital emergency services if nearby </li></ul></ul></ul><ul><ul><ul><li>Providers pressured to see the rising number of uninsureds </li></ul></ul></ul><ul><ul><ul><li>Medicaid, the primary financial source for the safety net, does not allow much cost shifting </li></ul></ul></ul>
  20. 20. Subsystems of US Health Care Delivery <ul><li>Integrated Delivery </li></ul><ul><li>The hallmark of the US health care industry: </li></ul><ul><ul><ul><li>to form integrated delivery systems (IDS) </li></ul></ul></ul><ul><li>IDS </li></ul><ul><ul><li>are various forms of ownership and links among hospitals, physicians and insurers </li></ul></ul><ul><ul><li>IDS’ objective: </li></ul></ul><ul><ul><ul><li>To have one health care organization deliver a range of services </li></ul></ul></ul>
  21. 21. Subsystems of US Health Care Delivery <ul><li>Integrated Delivery </li></ul><ul><li>IDS is </li></ul><ul><ul><li>A network of organizations that provides or arranges to provide a coordinated continuum of services to </li></ul></ul><ul><ul><ul><ul><ul><li>defined populations held clinically and fiscally accountable for outcomes and health status </li></ul></ul></ul></ul></ul>
  22. 22. <ul><li>No Central Governing Agency; </li></ul><ul><ul><li>Little Integration and Coordination </li></ul></ul><ul><li>Technology-Driven and Focuses on Acute Care </li></ul><ul><li>High on cost, Unequal in Access, and Average in Outcomes </li></ul><ul><li>Imperfect Market Conditions </li></ul><ul><li>Government as Subsidiary to the Private Sector </li></ul><ul><li>Market Justice vs. Social Justice </li></ul><ul><li>Multiple Players and Balance of Power </li></ul><ul><li>Quest for Integration and Accountability </li></ul>Characteristics Of The U.S. Health Care System
  23. 23. Characteristics Of The U.S. Health Care System <ul><li>No Central Governing Agency; </li></ul><ul><ul><li>Little Integration and Coordination </li></ul></ul><ul><ul><li>The US system is different from other developed countries </li></ul></ul><ul><ul><ul><li>It is not centrally-controlled </li></ul></ul></ul><ul><ul><ul><ul><li>Central systems are less complex, less costly </li></ul></ul></ul></ul><ul><ul><ul><li>Has different payment, insurance, and delivery mechanisms </li></ul></ul></ul><ul><ul><ul><li>Health care is financed both publicly and privately </li></ul></ul></ul><ul><ul><ul><ul><li>Look at Exhibit 1.1, page 8 </li></ul></ul></ul></ul>
  24. 24. Characteristics Of The U.S. Health Care System <ul><li>Technology-Driven and Focuses on Acute Care </li></ul><ul><ul><li>The US invests in research and innovations in new medical technology </li></ul></ul><ul><ul><li>Growth in science and technology helps create demand for new services, despite shrinking resources to finance sophisticated care </li></ul></ul>
  25. 25. Characteristics of The U.S. Health Care System <ul><li>Technology-Driven and Focuses on Acute Care </li></ul><ul><ul><li>Technology has had successful interventions, but is overused </li></ul></ul><ul><ul><ul><ul><li>This prohibits </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>employers extending benefits to part-time workers and </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>insurers lowering premiums </li></ul></ul></ul></ul></ul>
  26. 26. Characteristics Of The U.S. Health Care System <ul><li>High on Cost, Unequal in Access, and Average in Outcome </li></ul><ul><li>The United States spends more than any other developed country on health care </li></ul><ul><ul><li>Costs continue to rise at an alarming rate. </li></ul></ul><ul><ul><li>Many have limited access to basic care </li></ul></ul>
  27. 27. Characteristics Of The U.S. Health Care System <ul><li>High on Cost, Unequal in Access, and Average in Outcome </li></ul><ul><ul><li>Access </li></ul></ul><ul><ul><ul><li>The ability of an individual to obtain health care services when needed </li></ul></ul></ul>
  28. 28. Characteristics Of The U.S. Health Care System <ul><li>High on Cost, Unequal in Access, and Average in Outcome </li></ul><ul><ul><li>Access </li></ul></ul><ul><ul><ul><li>Is restricted in the US to those who: </li></ul></ul></ul><ul><ul><ul><ul><li>Have health insurance through an </li></ul></ul></ul></ul><ul><ul><ul><ul><li>employer </li></ul></ul></ul></ul><ul><ul><ul><ul><li>2. Are covered under a government program </li></ul></ul></ul></ul><ul><ul><ul><ul><li>3. Can afford to buy insurance out-of-pocket </li></ul></ul></ul></ul><ul><ul><ul><ul><li>4. Are able to pay for services privately </li></ul></ul></ul></ul>
  29. 29. <ul><li>High on Cost, Unequal in Access, and Average in Outcome </li></ul><ul><ul><li>The absence of insurance inhibits a patient’s ability to receive well-directed, coordinated, and continuous care to primary and specialty services if referred. </li></ul></ul>Characteristics Of The U.S. Health Care System
  30. 30. <ul><li>Imperfect Market Conditions </li></ul><ul><ul><li>Under national health care programs, </li></ul></ul><ul><ul><ul><li>patients have varying degrees of choice in selecting providers </li></ul></ul></ul><ul><ul><ul><li>true “free market” forces are virtually nonexistent. </li></ul></ul></ul>Characteristics Of The U.S. Health Care System
  31. 31. <ul><li>Imperfect Market Conditions </li></ul><ul><ul><li>In a free market, </li></ul></ul><ul><ul><ul><li>multiple patients (buyers) and providers (sellers) act independently. </li></ul></ul></ul><ul><ul><ul><li>patients should be able to choose their provider based on price and quality </li></ul></ul></ul>Characteristics Of The U.S. Health Care System
  32. 32. <ul><li>Imperfect Market Conditions </li></ul><ul><ul><li>For the health care market to be free, </li></ul></ul><ul><ul><ul><li>unrestrained competition must occur among providers, on the basis of price and quality </li></ul></ul></ul>Characteristics Of The U.S. Health Care System
  33. 33. <ul><li>Imperfect Market Conditions </li></ul><ul><ul><li>A free market requires that patients have </li></ul></ul><ul><ul><ul><li>information about the availability of various services </li></ul></ul></ul>Characteristics Of The U.S. Health Care System
  34. 34. <ul><li>Imperfect Market Conditions </li></ul><ul><ul><li>In a free market, patients as consumers must: </li></ul></ul><ul><ul><ul><li>directly bear the cost of services received. </li></ul></ul></ul><ul><ul><ul><li>make decisions about the purchase of health care services </li></ul></ul></ul>Characteristics Of The U.S. Health Care System
  35. 35. <ul><li>Government as Subsidiary to the Private Sector </li></ul><ul><ul><li>In most developed countries, </li></ul></ul><ul><ul><ul><ul><li>government plays a central role in the provision of health care. </li></ul></ul></ul></ul><ul><ul><li>In the US, </li></ul></ul><ul><ul><ul><ul><li>the private sector plays the dominant role because of American tradition, and the desire to limit government </li></ul></ul></ul></ul>Characteristics Of The U.S. Health Care System
  36. 36. <ul><li>Market Justice and Social Justice: Conflict Throughout Health Care </li></ul><ul><ul><li>Market justice and social justice are: </li></ul></ul><ul><ul><ul><li>two contrasting theories that govern the production and distribution of health care services in the United States. </li></ul></ul></ul>Characteristics Of The U.S. Health Care System
  37. 37. <ul><li>Multiple Players and Balance of Power </li></ul><ul><ul><ul><li>The key system players have been: </li></ul></ul></ul><ul><ul><ul><ul><ul><li>physicians </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>administrators of health care institutions </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>insurance companies </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>large employers </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>government </li></ul></ul></ul></ul></ul>Characteristics Of The U.S. Health Care System
  38. 38. <ul><li>Quest for integration and accountability </li></ul><ul><ul><ul><li>In the U.S., there is: </li></ul></ul></ul><ul><ul><ul><ul><li>a drive to use primary care as the organizing hub for continuous and coordinated health services with seamless delivery </li></ul></ul></ul></ul><ul><ul><ul><li>Accountability </li></ul></ul></ul><ul><ul><ul><ul><li>ethically providing quality health care in an efficient manner </li></ul></ul></ul></ul><ul><ul><ul><ul><li>safeguarding one’s own health and using resources sensibly </li></ul></ul></ul></ul>Characteristics Of The U.S. Health Care System
  39. 39. Health Care Systems Of Other Developed Countries <ul><li>Most western Europe has universal access </li></ul><ul><ul><li>Models for national health systems: </li></ul></ul><ul><ul><ul><li>1. National Health Insurance </li></ul></ul></ul><ul><ul><ul><li>2. National Health System </li></ul></ul></ul><ul><ul><ul><li>3. Socialized Health Insurance System </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Look at Table 1.1, page 16 </li></ul></ul></ul></ul></ul>
  40. 40. <ul><li>National Health Insurance </li></ul><ul><ul><ul><li>Canada uses this system </li></ul></ul></ul><ul><ul><li>Core of care delivered by private providers </li></ul></ul><ul><ul><li>Tighter consolidation of the financing, coordinated by government </li></ul></ul>Health Care Systems Of Other Developed Countries
  41. 41. <ul><li>National Health Systems </li></ul><ul><ul><ul><li>Great Britain uses this system </li></ul></ul></ul><ul><ul><li>finance a tax-supported national health insurance program: </li></ul></ul><ul><ul><ul><li>government manages the infrastructure for the delivery of medical care </li></ul></ul></ul><ul><ul><ul><li>most medical institutions are operated by government </li></ul></ul></ul><ul><ul><ul><li>most providers are government employees </li></ul></ul></ul>Health Care Systems Of Other Developed Countries
  42. 42. <ul><li>Socialized Health Insurance Systems </li></ul><ul><ul><ul><li>Germany uses this style </li></ul></ul></ul><ul><ul><li>Health care is financed through government-mandated contributions by employers and employees </li></ul></ul><ul><ul><li>Health care delivered by private providers </li></ul></ul><ul><ul><li>Sickness funds collect and pay for services </li></ul></ul><ul><ul><li>Insurance and payment is closely integrated </li></ul></ul><ul><ul><li>Delivery characterized by independent, private arrangements </li></ul></ul><ul><ul><li>Government exercises overall control </li></ul></ul>Health Care Systems Of Other Developed Countries
  43. 43. Systems Framework <ul><li>Systems consist of: </li></ul><ul><ul><li>a set of interrelated and interdependent components designed to achieve some common goals </li></ul></ul>
  44. 44. Systems Framework <ul><li>The systems framework: </li></ul><ul><ul><li>explains the structure of health care services in the U.S. based on the foundations </li></ul></ul><ul><ul><li>provides a logical arrangement of various components </li></ul></ul><ul><ul><li>demonstrates a progression from inputs to outputs </li></ul></ul>
  45. 45. <ul><li>The framework outlines: </li></ul><ul><ul><li>System Foundations </li></ul></ul><ul><ul><li>System Resources </li></ul></ul><ul><ul><li>System Processes </li></ul></ul><ul><ul><li>System Outcomes </li></ul></ul><ul><ul><li>System Outlook </li></ul></ul><ul><ul><ul><li>Look at Figure 1.2, page 18 </li></ul></ul></ul>Systems Framework
  46. 46. Conclusion <ul><li>The U.S. has a unique system of delivery, therefore </li></ul><ul><ul><ul><li>continuous and comprehensive care is not enjoyed by all Americans </li></ul></ul></ul><ul><ul><ul><li>it’s a patchwork of subsystems </li></ul></ul></ul><ul><ul><li>No country has a perfect system </li></ul></ul><ul><li>The Systems Framework is an </li></ul><ul><ul><li>organized approach to understanding the components of the US health care delivery system </li></ul></ul>
  47. 47. Slides created by: <ul><li>Elizabeth A. Berzas </li></ul><ul><li>Chair and Program Director </li></ul><ul><li>Our Lady of the Lake College </li></ul><ul><li>Department of Health Services </li></ul><ul><li>7434 Perkins Road </li></ul><ul><li>Baton Rouge, LA 70808 </li></ul><ul><li>(225) 786-1706 </li></ul><ul><li>[email_address] </li></ul><ul><li>www.ololcollege.edu </li></ul>

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