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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Health Care Structure
• Spectrum of health care delivery
• Various types of care
• Types of health care providers
• Health care facilities and their accreditation
14. Spectrum of Health Care Delivery
• Population-based public health practice
• Medical practice
• Long-term practice
• End-of-life practice
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. 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. 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
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. Independent Providers
• Specialized education and legal authority to
treat any health problem or disease
• Allopathic and osteopathic providers
• Nonallopathic providers
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Rehabilitation Centers
• Work to restore function
• May be part of a clinic or hospital, or
freestanding facilities
• May be inpatient or outpatient
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. 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. 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. 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
40. 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
41. 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
42. 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
44. The Cost of and Paying for Health Care
• Reimbursement
• Fee-for-service
• Packaged pricing
• Resource-based relative value scale
• Prepaid health care
• Prospective reimbursement
45. 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
48. 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
49. 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
50. 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
51. 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)
52. 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
53. 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
54. 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
55. 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
56. 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
58. 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
59. 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
60. 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
61. 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
62. 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?
