We need to understand health care system of other countries to learn how ours can evolve better.

1. Health System in USA
VIKASH RANJAN KESHRI
Moderator: Dr. P. R. Deshmukh

2. Outline of Presentation:
 Introduction
 Organizational structure
 Health Care Delivery System in US
 Components of US health System
 Major Stakeholders in the Health Care System in US
 Health Financing:
 Private Health Insurance
 Government Health Insurance:
Medicare
Medicaid
SCHIP
 Public Health System
 Health Care Reform in USA

3. Introduction:
 Complexity of Health System in USA
 Relies on a combination of governmental action,
market forces, and voluntary charitable
initiatives to deliver health services.
Government
Charitable
trust
Market
force

4. Organizational Structure:

5. Health care delivery system in USA:
 The health care delivery system in USA is in piecemeal.
 Overall the system goes like this:
Physician’s Office (Self-employed physician):
Contractual agreement is made between group of individual and physician office
Payment mode : can be direct or by reimbursement
Hospitals:
large number of primary care is also provided by the hospitals only
Payment mode: Direct or by reimbursement only.

6. Components of US Health System:
Health care
providers
Hospitals
Federal
Hospital
Non –
Federal
Hospital
Community
Hospital
Non profit For profit
State –
local
government
Ambulatory
Care
Provider
Mental and
substance
abuse care
Pharmacy
service
providers

7. Health Maintenance Organizations (HMOs):
 These are unique feature of US health system. These
organizations are within the private system in US only.
 Staff Model: Physicians work for HMOs.
 Group Model: HMO contract with separate physicians
group to provide its service.
 Pre- paid group practice (PPGP).
 IPA: Individual Practice Association.

8. Major Stakeholders:
Major
stakeholders
Health care
purchaser
Health care
providers
Other supplier,
policy makers/
regulator,
consumers

9. Table.1: Health Care Expenditure pattern (2010):
Total health care expenditure 100
Health Consumption Expenditure 93.7
Personal health care 84.1
Hospital services 30.5
Professional Services 27.1
Other health residential care 4.9
Home Care 2.7
Nursing Care and continuing care 5.5
Medical Product 13.2
Govt. Admn. 1.2
Govt. Health Insurance 5.4
Govt. public health 3.1
Investment: 6.3
Research 1.8
Structure and equipment 4.5

10. Figure: Personal Health Care Expenditure by type of
expenditure (2009).

11. Health Care Workforce:
Human Resource Number per 10,000
Active physician 27.4
Physician in patient care 25.4
Dentist 6
Table.2: Number of physician and Dentist per 10,000 populations
(2010)

12. Health-Care Purchasers:
Health Care
Purchaser
Private
Health
Insurance
Employer
supported
Self
supported
Government
Health
Insurance
Medicare Medicaid SCHIP VA

13. Flow Chart: over view of health financing

14. Medicare:
Three basic categories of beneficiaries:
 Individuals age 65 and older,
 Individuals who are permanently and completely
disabled, and
 Individuals with end-stage renal disease.
Four major components:
PART - A
PART - B
PART - C
PART - D

15. PART- A
Coverage:
Coverage under part- A is mandatory for all eligible beneficiary:
 Short-stay hospital inpatient services,
 Skilled nursing facilities,
 Home health services, and
 Hospice care.
Financing for part- A:
 Medicare Trust Fund: financed by employer and employee payroll
tax.
 Out of pocket deductible for hospital care.
 Fixed amount for an episode of care.

16. PART - B
 Covers physician care and other outpatient services.
 Optional benefit
 Beneficiaries are responsible for paying a monthly premium.
 beneficiaries exposed to significant out-of-pocket costs, including
deductibles, copayments, and costs for non-covered services.
Part C:
 Component of the Medicare program, covers an array of managed
care plans an alternative to the traditional Medicare program.
 Medicare +Choice program.
Part – D:
 Coverage for outpatient prescription drugs.
 As part of the Medicare Modernization Act of 2003 and
 Took effect during 2006.

17. Medicare
Age > 65 yrs. : Medicare 22.1 %
Medicaid 8.8%
Employee insured plan 32.7 %
Medigap 21.5 %
Medicare free for service 14.9%
total population covered by
Medicare
47.1 million
Free for all coverage 35,360
Table.3: Medicare and Medicaid coverage for age 65
yrs. and above.

18. Medicaid:
 Single largest health-care program in the country.
 Jointly financed and administered by the federal government and individual state
governments.
 Beneficiary:
Poor, Elderly, Disabled, Children, Pregnant Women and Parents of young
children
Minimum services covered:
 Inpatient and outpatient medical care,
 Physician services,
 Laboratory and imaging services,
 Family planning services,
 Mental health services,
 Early childhood diagnostic screening and treatment services, and
 Selected long-term care services including nursing home care and home health care.
Optional services include:
 rehabilitation care,
 dental care, and
 home and
 community-based long-term care services.

19. Table.3: Medicaid coverage on the basis of eligibility in year
2009
Total beneficiaries 56.0 Million
Aged 65 or above 6.5%
Blind or disabled 14.0%
Adult in the family of
dependent children
22.6%
Children < 21 years 48.4%
Others 8.55%

20. Overall Medicaid coverage:

22. SCHIP: State Children’s Health Insurance
Program
 Started in 1997.
 For low-income children not eligible for the traditional Medicaid
program.
 uninsured children who reside in families with incomes below 200%
of the FPL or whose family has an income 50% higher than the
state’s Medicaid eligibility threshold.
 Jointly financed and administered by the federal government and
individual state governments.
Veteran’s Administrations:
 Federally administered program for veterans of the military.
 Health care is delivered in government-owned VA hospitals and
clinics.

23. Private Health Insurance:
 Employer-sponsored insurance:
 Principle mode
 Part of the benefits package for employees.
 Administration:
 Private companies, both for-profit (e.g. Aetna, Cigna) and non-for-profit
(e.g. Blue Cross/Blue Shield).
 Self-Insured Company:
 Pay for all health care costs incurred by employees directly (general
motors).
 Private non-group (individual market):
 Population that is self-employed or retired.

24. USA: Public Health System:
Public Health’s Three Core Functions: (as defined by
IOM)
 Assurance
 Policy Development
 Assessment
The Ten Essential Services:
 Based on the three core principles, ten essential services
has been defined:

26. Unique feature of US public health system:
 Council on Linkages between Public Health Practice
and Academia:
 public health practice is “de-coupled” from its academic base
 to facilitate additional activities that would enhance the
practice/academic connection
 Organizations under the Public Health System:
 The current operational arms of the PHS include:
 National Institutes of Health (NIH),
 Centers for Disease Control and Prevention (CDC),
 Health Resources and Services Administration (HRSA),
 Indian Health Service (IHS),
 Food and Drug Administration (FDA),
 Agency for Toxic Substances and Disease Registry (ATSDR) (administered
by the CDC), and Substance Abuse and Mental Health Administration
(SAMHA)

27. The Ten Essential Services:
 The three core functions were further expanded to a list of Ten Essential Community
Health Services that would more clearly define the services communities need in
order to achieve high levels of healthfulness.6 Those Ten Essential Services are:
 Monitor health status to identify community health problems.
 Diagnose and investigate health problems and health hazards in the community.
 Inform, educate, and empower people about health issues.
 Mobilize community partnerships to identify and solve health problems.
 Develop policies and plans that support individual and community health efforts.
 Enforce laws and regulations that protect health and ensure safety.
 Link people to needed personal health services and ensure the provision of health
care when otherwise unavailable.
 Ensure a competent public health and personal health workforce.
 Evaluate effectiveness, accessibility, and quality of personal and population-based
health services.
 Research for new insights and innovative solutions to health problems.

28. THE STATE PUBLIC HEALTH ROLE:
 Assessment of the health needs in the state based on statewide data
collection:
 Assurance of an adequate statutory base for health activities in the state
 Establishment of statewide health objectives, delegating power to locals
as appropriate and holding them accountable
 Assurance of appropriate organized statewide effort to develop and
maintain essential, personal, educational, and environmental health
services;
 Provision of access to necessary services; and solution of problems
inimical to health
 Guarantee of a minimum set of essential health services
 Support of local service capacity.

29. Health Care Reform: 2010 (Obama Care)
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30. References:
 Wallace RB, Kohatsu N. editors. Maxcy- Rosenue – Last: Public
Health and Preventive Medicine. 15th ed. New York; The Mac – Graw
hill Company: 2008. P1217- 50.
 Detel R. McEwen J. Beaglehole R. Tanaka H. editors. Oxford
Textbook of Public Health. 2nd edition. New York; Oxford University
Press:
 US Department of Health and Human Services, Centre for Disease
Control, National Centre for Health Statistics. Health – United States
2011: With Special Feature on Socioeconomic Status and Health.
Hyattsville, MD. 2012.
 Chua KP. Overview of American Health System. Available from URL: