Health Care Deliveryin the United States      Chapter 13
Introduction• Health care delivery in U.S. is unlike other  developed countries  • Is delivered by an array of providers i...
History of Health Care Delivery in the U.S.• Self-care has been a category of health care  throughout history and today  •...
History of Health Care Delivery in the U.S.• Early medical education not grounded in  science; experience-based only, prio...
Health Care Delivery in the        Late 1800’s – Early 1900’s• Care moved from patient’s home to  physician’s office and h...
Health Care Delivery in the        Late 1800’s – Early 1900’s• Early 1920s chronic diseases passed  communicable as leadin...
Health Care Delivery – 1940s and 1950s• WWII impact  • Due to wage restrictions employers used health    insurance to lure...
Health Care Delivery – 1960s• Late 1950s had overall shortage of quality care  and maldistribution of health care services...
Health Care Delivery – 1970s• Health Maintenance Organization Act of 1973• National Health Planning and Resources  Develop...
Health Care Delivery – 1980s• Reagan and Congress eliminated Health  System Agencies• Deregulation of health care delivery...
Health Care Delivery – 1990s• American Health Security Act of 1993• Managed care  • Achieve efficiency  • Control utilizat...
Health Care Delivery in the 21st Century• 2010 – U.S. health care costs $2.6 trillion;  17.3% GDP  • Health care costs out...
Health Care Structure• Spectrum of health care delivery  • Various types of care• Types of health care providers• Health c...
Spectrum of Health Care Delivery•   Population-based public health practice•   Medical practice•   Long-term practice•   E...
Population-Based Practice• Interventions aimed at disease prevention and  health promotion• Health education  • Empowermen...
Medical Practice• Primary medical care  • Clinical preventive services; first-contact    treatment; ongoing care for commo...
Long-Term Practice• Restorative care  • Provided after surgery or other treatment     • Rehab care, therapy, home care    ...
End-of-Life Practice• Services provided shortly before death• Hospice care  • Terminal diagnosis  • Variety of settings
Spectrum of Health Care Delivery
Types of Health Care Providers• 14.5 million workers in U.S. (10.4% of pop.)  • 41.3% in hospitals; 25.6% in ambulatory ca...
Independent Providers• Specialized education and legal authority to  treat any health problem or disease• Allopathic and o...
Allopathic and Osteopathic Providers• Allopathic providers  • Produce effects different from those of diseases  • Doctors ...
Nonallopathic Providers• Nontraditional means of health care• Complementary and Alternative medicine  (CAM)  • Used togeth...
Limited (or Restricted) Care Providers• Advanced training in a health care specialty• Provide care for a specific part of ...
Nurses• Over 4 million working in nursing profession• Licensed Practical Nurses (LPNs)  • 1-2 years of education in vocati...
Nonphysician Practitioners• Practice in many areas similar to physicians,  but do not have MD or DO degrees• Training beyo...
Allied Health Care Professionals• Assist, facilitate, and complement work of  physicians and other health care specialists...
Public Health Professionals• Work in public health organizations• Usually financed by tax dollars• Available to everyone; ...
Health Care Facilities & Their Accreditation• Physical settings where health care is provided• Inpatient care facilities  ...
Inpatient Care Facilities• Hospitals, nursing homes, assisted-living• Hospitals often categorized by ownership  • Private ...
Clinics•   Two or more physicians practicing as a group•   Do not have inpatient beds•   For-profit and not-for-profit•   ...
Outpatient Care Facilities• Care in a variety of settings, but no overnight  stay regardless of why patient is in the faci...
Rehabilitation Centers• Work to restore function• May be part of a clinic or hospital, or  freestanding facilities• May be...
Long-Term Care Options• Nursing homes, group homes, transitional  care, day care, home health care• Home health care  • Gr...
Accreditation of Health Care Facilities• Assists in determining quality of health care  facilities• Process by which an ag...
Health Care System Function• U.S. “system” unique compared to other countries  • Recent decades’ challenges led to new    ...
Structure of the Health Care System• U.S. structure – complex, expensive, many  stakeholders, intertwined policies, politi...
Access to Health Care
Access to Health Care• Variety of means to gain access  • Insurance coverage and generosity of coverage    are major deter...
Access to Health Care• 8 out of 10 uninsured are from working  families• Medically indigent• Working poor• Major component...
Quality of Health Care• Doing the right thing, at the right time, in the right  way, for the right people, and having the ...
The Cost of and Paying for Health Care
The Cost of and Paying for Health Care•   Reimbursement•   Fee-for-service•   Packaged pricing•   Resource-based relative ...
Health Insurance• A risk and cost-spreading process, like other  insurance  • Cost is shared by all in the group  • Genera...
Health Insurance Policy•   Policy•   Premiums•   Deductible•   Co-insurance•   Copayment•   Fixed indemnity•   Pre-existin...
Types of Health Insurance Coverage
The Cost of Health Insurance• Cost of insurance mirrors cost of care• In U.S., burden falls primarily on the  employer, th...
Self-Funded Insurance Programs• Programs created for/by employers rather than  using commercial insurance carriers• Many b...
Health Insurance Provided by the                Government• Government health insurance plans only available to  select gr...
Medicare• Covers more than 46.5 million people• Federal health insurance program for those:  • 65+, permanent kidney failu...
Medicare• Part A – mandatory; has deductible & co-  insurance• Part B – those in part A automatically enrolled  unless dec...
Medicaid• Health insurance program for low-income; no  age requirement• 46+ million covered by Medicaid• Eligibility deter...
CHIP• Created in 1997 for 10 years  • Reauthorized in 2009 through 2013     • Funding assisted by increase in federal exci...
Problems with Medicare and Medicaid• Programs created to help provide health care  to those who might have impossibilities...
Supplemental Health Insurance• Help cover out-of-pocket costs not covered  through primary insurance  •   Medigap  •   Spe...
Who pays for long-term care?
Managed Care• Goal to control costs by controlling health care  utilization• 2010 – 135 million enrolled in managed care p...
Types of Managed Care• Preferred provider organization (PPO)• Exclusive provider organization (EPO)• Health maintenance or...
Other Arrangements for           Delivering Health Care• National health insurance  • A system in which the federal govern...
Health Care Reform in the United States• Consumer-directed health plans (CDHPs)  • Consumer responsibility for health care...
Discussion Questions• How does payment for health care services  affect the various types of health care  providers now an...
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  1. 1. Health Care Deliveryin the United States Chapter 13
  2. 2. Introduction• Health care delivery in U.S. is unlike other developed countries • Is delivered by an array of providers in a variety of settings • Is paid for in a variety of ways• Is U.S. health care a “system?”
  3. 3. History of Health Care Delivery in the U.S.• Self-care has been a category of health care throughout history and today • Assumed self-care occurs before seeking professional help• From colonial times through late 1800’s, anyone trained or untrained could practice medicine• Past medical education not as rigorous as today
  4. 4. History of Health Care Delivery in the U.S.• Early medical education not grounded in science; experience-based only, prior to 1870• Most care was provided in patients’ homes• Hospitals only in large cities and seaports • Functioned more in a social welfare manner • Not clean; unhygienic practice• Almshouses• Pesthouses
  5. 5. Health Care Delivery in the Late 1800’s – Early 1900’s• Care moved from patient’s home to physician’s office and hospital • Building and staffing better; designed for patient care; trained people; medical supplies • Reduced travel time• Science had bigger role in medical education• Mortality decline due to improved public health measures
  6. 6. Health Care Delivery in the Late 1800’s – Early 1900’s• Early 1920s chronic diseases passed communicable as leading causes of death• New procedures: X-ray, specialized surgery, chemotherapy, ECG• Training: doctors and nurses more specialized• 1929 – 3.9% GDP on health care• Two party system – patients and physicians • Physicians collected own bills, set and adjusted prices based on ability to pay
  7. 7. Health Care Delivery – 1940s and 1950s• WWII impact • Due to wage restrictions employers used health insurance to lure workers • Huge technical strides in 1940s and 1950s• Hill-Burton Act• Improved procedures, equipment, facilities meant rise in cost of health care• Concept of health care as basic right vs. privilege
  8. 8. Health Care Delivery – 1960s• Late 1950s had overall shortage of quality care and maldistribution of health care services• Increased interest in health insurance• Third-party payment system became standard method of payment• Cost of health care rose• Increased access, little expense for those with insurance; those without unable to afford care• 1965 Medicare and Medicaid
  9. 9. Health Care Delivery – 1970s• Health Maintenance Organization Act of 1973• National Health Planning and Resources Development Act of 1974 • Health Systems Agencies in place to cut costs and prevent building unnecessary facilities and purchasing unnecessary equipment
  10. 10. Health Care Delivery – 1980s• Reagan and Congress eliminated Health System Agencies• Deregulation of health care delivery• Proliferation of new medical technology• Questions in medical ethics• Elaborate health insurance programs
  11. 11. Health Care Delivery – 1990s• American Health Security Act of 1993• Managed care • Achieve efficiency • Control utilization • Determine prices and payment• 1996 – U.S. health care bill $1 trillion; 13.6% GDP• CHIP
  12. 12. Health Care Delivery in the 21st Century• 2010 – U.S. health care costs $2.6 trillion; 17.3% GDP • Health care costs outpacing inflation for past few decades • America spends more per capita annually on health care than any other nation• Still no national Patient Bill of Rights• Health Savings Accounts• 2010 – Affordable Care Act
  13. 13. Health Care Structure• Spectrum of health care delivery • Various types of care• Types of health care providers• Health care facilities and their accreditation
  14. 14. Spectrum of Health Care Delivery• Population-based public health practice• Medical practice• Long-term practice• End-of-life practice
  15. 15. Population-Based Practice• Interventions aimed at disease prevention and health promotion• Health education • Empowerment and motivation• Much takes place in governmental health agencies • Also occurs in a variety of other settings
  16. 16. Medical Practice• Primary medical care • Clinical preventive services; first-contact treatment; ongoing care for common conditions• Secondary medical care • Specialize attention and ongoing management• Tertiary medical care • Highly specialized and technologically sophisticated medical and surgical care • For unusual and complex conditions
  17. 17. Long-Term Practice• Restorative care • Provided after surgery or other treatment • Rehab care, therapy, home care • Inpatient and outpatient units, nursing homes, other settings• Long-term care • Help with chronic illnesses and disabilities • Time-intensive skilled care to basic daily tasks • Nursing homes and various settings
  18. 18. End-of-Life Practice• Services provided shortly before death• Hospice care • Terminal diagnosis • Variety of settings
  19. 19. Spectrum of Health Care Delivery
  20. 20. Types of Health Care Providers• 14.5 million workers in U.S. (10.4% of pop.) • 41.3% in hospitals; 25.6% in ambulatory care settings; 16.3% in nursing/residential facilities • Over 200 types of careers in industry • Independent providers • Limited care providers • Nurses • Nonphysician practitioners • Allied health care professionals • Public health professionals
  21. 21. Independent Providers• Specialized education and legal authority to treat any health problem or disease• Allopathic and osteopathic providers• Nonallopathic providers
  22. 22. Allopathic and Osteopathic Providers• Allopathic providers • Produce effects different from those of diseases • Doctors of Medicine (MDs)• Osteopathic providers • Relationship between body structure & function • Doctors of Osteopathic Medicine (DOs)• Similar education and training• Most DOs work in primary care
  23. 23. Nonallopathic Providers• Nontraditional means of health care• Complementary and Alternative medicine (CAM) • Used together with conventional medicine, therapy is considered “complementary”; in place of considered “alternative” • Chiropractors, acupuncturists, naturopaths, etc. • Natural products, mind-body medicine, manipulation, etc.
  24. 24. Limited (or Restricted) Care Providers• Advanced training in a health care specialty• Provide care for a specific part of the body• Dentists, optometrists, podiatrists, audiologists, psychologists, etc.
  25. 25. Nurses• Over 4 million working in nursing profession• Licensed Practical Nurses (LPNs) • 1-2 years of education in vocational program • Pass licensure exam• Registered Nurses (RNs) • Completed accredited academic program • State licensure exam• Advanced Practice Nurses (APNs) • Master or Doctoral degrees
  26. 26. Nonphysician Practitioners• Practice in many areas similar to physicians, but do not have MD or DO degrees• Training beyond RN, less than physician• Nurse practitioners, certified midwives, physician assistants
  27. 27. Allied Health Care Professionals• Assist, facilitate, and complement work of physicians and other health care specialists• Categories • Laboratory technologist/technicians • Therapeutic science practitioners • Behavioral scientists • Support services• Education and training varies
  28. 28. Public Health Professionals• Work in public health organizations• Usually financed by tax dollars• Available to everyone; primarily serve economically disadvantaged• Public health physicians, environmental health workers, epidemiologists, health educators, public health nurses, research scientists, clinic workers, biostatisticians, etc.
  29. 29. Health Care Facilities & Their Accreditation• Physical settings where health care is provided• Inpatient care facilities • Patient stays overnight• Outpatient care facilities • Patient receives care and does not stay overnight
  30. 30. Inpatient Care Facilities• Hospitals, nursing homes, assisted-living• Hospitals often categorized by ownership • Private – profit making; specialty hospitals • Public – supported and managed by government jurisdictions • Voluntary – not-for-profits; ½ of U.S. hospitals• Teaching and nonteaching hospitals• Full-service or limited-service hospitals
  31. 31. Clinics• Two or more physicians practicing as a group• Do not have inpatient beds• For-profit and not-for-profit• Tax funded • Public health clinics, community health centers • Over 1,100 community health centers in U.S. • Support primary health care needs of underserved populations in the U.S.
  32. 32. Outpatient Care Facilities• Care in a variety of settings, but no overnight stay regardless of why patient is in the facility • Health care practitioners’ offices, clinics, primary care centers, ambulatory surgery centers, urgent care centers, services offered in retail stores, dialysis centers, imaging centers
  33. 33. Rehabilitation Centers• Work to restore function• May be part of a clinic or hospital, or freestanding facilities• May be inpatient or outpatient
  34. 34. Long-Term Care Options• Nursing homes, group homes, transitional care, day care, home health care• Home health care • Growing due to restructuring of health care system, technological advances, and cost containment
  35. 35. Accreditation of Health Care Facilities• Assists in determining quality of health care facilities• Process by which an agency or organization evaluates and recognizes an institution as meeting certain predetermined standards• Joint Commission • Predominant accrediting organization
  36. 36. Health Care System Function• U.S. “system” unique compared to other countries • Recent decades’ challenges led to new legislation• Affordable Care Act • Goal: to put American consumers back in charge of their health coverage and care • Signed into law March, 2010; changes to be implemented 2010-2020; some effective mid- 2010; bulk go into effect 2014
  37. 37. Structure of the Health Care System• U.S. structure – complex, expensive, many stakeholders, intertwined policies, politics• Major issues: • Cost containment, access, quality • All equally important; expansion of one compromises other two
  38. 38. Access to Health Care
  39. 39. Access to Health Care• Variety of means to gain access • Insurance coverage and generosity of coverage are major determinants of access to health care • 2009 – 46.3 million uninsured (15.4%); 58.5 million uninsured for part of the year (19.4%) • Likelihood of being uninsured greater for those: young, less education, low income, nonwhite • Greatest reason for lack of insurance: cost
  40. 40. Access to Health Care• 8 out of 10 uninsured are from working families• Medically indigent• Working poor• Major component of Affordable Care Act is increasing the number of Americans with health insurance
  41. 41. Quality of Health Care• Doing the right thing, at the right time, in the right way, for the right people, and having the best results • Quality health care should be: • Effective • Safe • Timely • Patient centered • Equitable • Efficient
  42. 42. The Cost of and Paying for Health Care
  43. 43. The Cost of and Paying for Health Care• Reimbursement• Fee-for-service• Packaged pricing• Resource-based relative value scale• Prepaid health care• Prospective reimbursement
  44. 44. Health Insurance• A risk and cost-spreading process, like other insurance • Cost is shared by all in the group • Generally “equitable,” but increased risk may lead to increased costs
  45. 45. Health Insurance Policy• Policy• Premiums• Deductible• Co-insurance• Copayment• Fixed indemnity• Pre-existing condition • HIPPA
  46. 46. Types of Health Insurance Coverage
  47. 47. The Cost of Health Insurance• Cost of insurance mirrors cost of care• In U.S., burden falls primarily on the employer, then the employee • Increased worker share of premium • Raising deductibles • Increasing prescription co-payments • Increasing number of exclusions• Cost of policy determined by risk of group and amount of coverage provided
  48. 48. Self-Funded Insurance Programs• Programs created for/by employers rather than using commercial insurance carriers• Many benefits to the employer• Generally for larger companies, unless low- risk employees
  49. 49. Health Insurance Provided by the Government• Government health insurance plans only available to select groups • Medicare • Medicaid • Children’s Health Insurance Program • Veterans Administration benefits • Indian Health Services • Federal employees • Health care for the uniformed services • Prisoners
  50. 50. Medicare• Covers more than 46.5 million people• Federal health insurance program for those: • 65+, permanent kidney failure, certain disabilities• SSA handles enrollment• Contributory program through FICA tax• Four parts • Hospital insurance (Part A), medical insurance (Part B), managed care plans (Part C), prescription drug plans (Part D)
  51. 51. Medicare• Part A – mandatory; has deductible & co- insurance• Part B – those in part A automatically enrolled unless decline; has deductible & co-insurance• Part C – offered by private insurance companies; not available in all parts of U.S.• Part D – optional; run by insurance companies; monthly premiums; large number of plan available; complex to navigate• Uses DRGs
  52. 52. Medicaid• Health insurance program for low-income; no age requirement• 46+ million covered by Medicaid• Eligibility determined by each state; very costly budget item for states• Noncontributory program
  53. 53. CHIP• Created in 1997 for 10 years • Reauthorized in 2009 through 2013 • Funding assisted by increase in federal excise tax rate on tobacco• 2009 – 7.8 million children enrolled• Targets low-income children ineligible for Medicaid• State/federal program
  54. 54. Problems with Medicare and Medicaid• Programs created to help provide health care to those who might have impossibilities of obtaining health insurance• Recurrent problems: • Some providers do not accept Medicare or Medicaid as forms of payment • Medicare/Medicaid fraud
  55. 55. Supplemental Health Insurance• Help cover out-of-pocket costs not covered through primary insurance • Medigap • Specific-disease insurance • Fixed-indemnity • Long-term care insurance • Preserve financial assets, prevent need for family or friends to provide care, enable people to stay independent longer, easier to go into facility of choice
  56. 56. Who pays for long-term care?
  57. 57. Managed Care• Goal to control costs by controlling health care utilization• 2010 – 135 million enrolled in managed care plan• Managed by MCOs • Have agreements with providers to offer services at reduced cost• Common features – provider panels, limited choice, gatekeeping, risk sharing, quality management and utilization review
  58. 58. Types of Managed Care• Preferred provider organization (PPO)• Exclusive provider organization (EPO)• Health maintenance organization (HMO) • Staff model HMO • Independent practice association (IPA) • Other HMO models
  59. 59. Other Arrangements for Delivering Health Care• National health insurance • A system in which the federal government assumes responsibility for health care costs of entire population; primarily paid for with tax dollars • U.S. only developed country without national health care plan • Seven failed attempts at national health care in U.S. over past 70 years• State health plans
  60. 60. Health Care Reform in the United States• Consumer-directed health plans (CDHPs) • Consumer responsibility for health care decisions with tax-sheltered accounts • Health savings accounts • High reimbursement arrangements• Affordable Care Act
  61. 61. Discussion Questions• How does payment for health care services affect the various types of health care providers now and in the future?• What changes will need to occur for all U.S. citizens to have affordable health insurance?• Is the Affordable Care Act going to effectively combat the numerous problems within the U.S. health care system?

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