The U.S. Healthcare System An overview of what's what

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The U.S. Healthcare System An overview of what's what

  1. 1. The U.S. Healthcare System • An overview of what’s what 1
  2. 2. Stakeholders • Patients • Employers • Providers • Payers • Government • Accreditors • Purchasers 2
  3. 3. What’s My Aim? • Patients 3
  4. 4. What’s My Aim? • Patients – Unlimited wants / Access – Effective treatment • Cure; symptoms; safety – Efficiency of care – Economy of care – Education; knowledge – Low administrative burden – Respect 4
  5. 5. Community Need Plan to Improve Vision back Design, Redesign Customer Knowledge Suppliers Customers Process INPUTS OUTPUTS 5
  6. 6. Number of People, United States 1990 - 2020 85 + 65 + 60,000,000 50,000,000 40,000,000 30,000,000 20,000,000 10,000,000 0 1990 2000 Year 2010 2020 US Census Bureau released 12/23/99; 1/13/2000 6
  7. 7. What’s My Aim? • Employers 7
  8. 8. What’s My Aim? • Employers – Satisfied employees – Contain health care costs – Employee wellness – Profitability of the firm 8
  9. 9. What’s My Aim? • Providers • Who are? 9
  10. 10. Care Providers • Examples – Pharmacists – Physicians – Physician Assistant – Nurses / Nurse Practitioner – Dentists 10
  11. 11. What’s My Aim? • Providers – Improve health of patients – Autonomy – Authority – Economic viability of the practice – Professional development – Research 11
  12. 12. What’s My Aim? • Payers – Who are? 12
  13. 13. What’s My Aim? • Payers – Coordination of transactions – Rate setting – Risk assessment and underwriting – Information – Economic viability – Legal / ethical considerations 13
  14. 14. Health Insurance in the United States None 14% Public 64% 24% Private US Census Bureau Current Population Survey http://www.census.gov/prod/2001pubs/p60-215.pdf 14
  15. 15. Health Insurance in the United States Private Self- purchase Uninsured + Rx Limited Rx 8% 14% Medicaid Usually No Rx 10% 13% Medicare 64% Military Employer - Based US Census Bureau Current Population Survey http://www.census.gov/prod/2001pubs/p60-215.pdf 15
  16. 16. Components of the Care Care Premium Payment Physicians and Claims and Other Health Drugs and Consumer Providers Medical Supplies Services Hospitals 43% 32% 13% 10% Nursing and Home Health Care 2% 16 HIAA Issue Brief: “Why Do Health Insurance Premiums Rise?” March 2000
  17. 17. U.S. Health Care Spending 1.9 2.0 1.6 Overall 1.5 Rx Drugs 1.3 U.S.Trillion $ 1.0 0.9 0.6 0.5 0.2 0.1 5% 11% 0.0 1970 1980 1990 1995 2000 2005 2008 year National Health Statistics Group, Office of the Actuary, Health Care Financing Administration: National Health Accounts 17 HIAA Issue Brief: “Why Do Health Insurance Premiums Rise?” March 2000: Source: CMS Data
  18. 18. What’s My Aim? Government Government • Federal • State 18
  19. 19. What’s My Aim? • Government • Government • Federal • State – Provide for those – Provide for those whom the market does whom the market does not serve not serve – Medicaid – CMS – Local programs – Prevention – Mental health – Research – Elderly – Regulate – Regulate 19
  20. 20. What’s My Aim? • Accreditors 20
  21. 21. What’s My Aim? • Accreditors – Quality – Audit – Unintended consequences of cost containment – Evidence-based medicine – Credentialing 21
  22. 22. Care Settings 22
  23. 23. Care Settings • Community / Ambulatory – Outpatients – Homebound – Assisted Living / Adult Day Care • Inpatient – Hospital – Institutionalized • Long-term Care – Nursing Home / Institutionalized 23
  24. 24. Primary Care • Physician – PA, NP • Settings – Office – Clinic – ED 24
  25. 25. Ancillary Care Services • Pharmacy • Laboratory • Radiology • Physical Therapy • Alternative Therapies? 25
  26. 26. Who Pays? • Private – Indemnity insurance – Managed care • HMO, PPO, POS – Payment • Prospective (capitation) • Retrospective – Patient purchased 26
  27. 27. Who Pays? • Public – Medicaid • FFS, Managed care – Medicare • Medicare+Choice – Other • Champus, SCHIP, etc 27
  28. 28. Who Manages? • Trends – Cost inflation • Technology • Consumer demands / psychology • Market-based system • Prescription drugs • Demographics – Baby boom • Chronic disease • Lifestyles – rationing 28
  29. 29. Who Manages? • Trends – Quality of care • Satisfaction • Safety – Error – Risk • Efficiency of health care delivery – Reduce waste 29
  30. 30. Who Manages? • Regulation / Accreditation – CMS – QIOs – NCQA – JCAHO – Patients’ Rights – IOM 30

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