chapter 1 major characteristics of u.s. health care delivery
TRANSCRIPT
Chapter 1
Major Characteristics of
U.S. Health Care Delivery
Introduction
The United States has a unique system of health care delivery.
The US health care delivery system is complex and massive.
Introduction “Health care delivery” and “health services
delivery”
Can have slightly different meanings,but in a broad sense, both terms refer to the:
major components of the system
processes that enable people to receive health care.
provision of health care services to patients.
Introduction In contrast to the United States,
most developed countries have national health insurance programs
referred to as “universal access”
• provide routine and basic health care
• run by the government and financed through general taxes.
All Americans are not “entitled” to routine and basic health care services.
Introduction 187.4 million Americans have private health insurance
coverage,
35.2 million Medicare beneficiaries, and
31.5 million Medicaid recipients.
Health insurance can be bought from:
1,000 health insurance companies
70 BlueCross/BlueShield plans
The managed care sector includes approximately:
540 licensed health maintenance organizations (HMOs)
925 preferred provider organizations (PPOs)
Subsystems of US Health Care Delivery
•Managed Care
•Military
•Vulnerable Populations
•Integrated Delivery
Managed Care
A system of health care delivery that:
1) seeks to achieve efficiency by integrating the basic functions of healthcare delivery
2) employs mechanisms to control (manage) utilization of medical services
3) determines the price at which the services are purchased and how much the providers get paid.
Subsystems of US Health Care Delivery
Managed Care
Is the most dominant health care delivery system in the United States and available to most Americans.
Employers and government are the primary financiers of managed care
An MCO functions like • an insurance company
– it promises to provide health care services contracted under the health plan to the enrollees of the plan.
Subsystems of US Health Care Delivery
Managed Care
Enrollee refers to: a member an individual covered under the plan
Health plan: a contractual arrangement between the MCO and
the enrollee• includes a list of covered health services to which
enrollees are entitled
uses selected providers• usually primary care, general practioners
--the “gatekeepers”
• Look at Figure 1.1, page 5
Subsystems of US Health Care Delivery
Subsystems of US Health Care Delivery
Military
The military medical care system is available free of charge to:
active duty military personnel of the U.S. Army, Navy, Air Force, and Coast Guard,
certain uniformed nonmilitary services such as • the Public Health Services and
• the National Oceanographic and Atmospheric Association (NOAA)
Subsystems of US Health Care Delivery
Military
The military medical care system is
well-organized
highly integrated
comprehensive• covers preventative care
Subsystems of US Health Care Delivery
Military
TRICARE
Financed by the military, and covers families, dependents or retired military
Subsystems of US Health Care Delivery
Military
The VA health care system
available to retired veterans
focuses on hospital, mental health and long-term care
Is one of the largest and oldest (1946) organized health systems in the world
Subsystems of US Health Care Delivery
Military
The mission of the VA health care system:
Provide medial care, education and training, research, contingency support and emergency management for the Department of Defense medical care system.
Subsystems of US Health Care Delivery
Military
The VA health care system has:
over 1,100 sites 172 hospitals 206 counseling centers 40 residential care facilities 73 home health programs, and
provides care to 3.6 million
Subsystems of US Health Care Delivery
Military
The VA:
Budgets over $20 billion
Employs over 182,000
Affiliates with 13,000 physicians 53,000 nurses 3,500 pharmacists
Subsystems of US Health Care Delivery
Military
The VA is:
organized into 22 geographically-distributed Veterans Integrated Service Networks (VISN)
• Each VISN
– coordinates its own services
– receives federal funds
Subsystems of US Health Care Delivery
Vulnerable Populations
Particularly the poor, uninsured, minorities and immigrants
live in disadvantaged communities and receive care from “safety net” providers.
Subsystems of US Health Care Delivery
Vulnerable Populations
Safety nets are not secure
Provider type and availability vary
Some individuals forego care and seek hospital emergency services if nearby
Providers pressured to see the rising number of uninsureds
Medicaid, the primary financial source for the safety net, does not allow much cost shifting
Subsystems of US Health Care Delivery
Integrated Delivery
The hallmark of the US health care industry: to form integrated delivery systems (IDS)
IDS are various forms of ownership and links among
hospitals, physicians and insurers
IDS’ objective: To have one health care organization deliver a
range of services
Subsystems of US Health Care Delivery
Integrated Delivery
IDS is
A network of organizations that provides or arranges to provide a coordinated continuum of services to
– defined populations held clinically and fiscally accountable for outcomes and health status
No Central Governing Agency; Little Integration and Coordination
Technology-Driven and Focuses on Acute Care
High on cost, Unequal in Access, and Average in Outcomes
Imperfect Market Conditions
Government as Subsidiary to the Private Sector
Market Justice vs. Social Justice
Multiple Players and Balance of Power
Quest for Integration and Accountability
Characteristics Of The U.S. Health Care System
Characteristics Of The U.S. Health Care System
No Central Governing Agency; Little Integration and Coordination
The US system is different from other developed countries
It is not centrally-controlled• Central systems are less complex, less costly
Has different payment, insurance, and delivery mechanisms
Health care is financed both publicly and privately
• Look at Exhibit 1.1, page 8
Characteristics Of The U.S. Health Care System
Technology-Driven and Focuses on Acute Care
The US invests in research and innovations in new medical technology
Growth in science and technology helps create demand for new services, despite shrinking resources to finance sophisticated care
Characteristics of The U.S. Health Care System
Technology-Driven and Focuses on Acute Care Technology has had successful
interventions, but is overused
• This prohibits
– employers extending benefits to part-time workers and
– insurers lowering premiums
Characteristics Of The U.S. Health Care System
High on Cost, Unequal in Access, and Average in Outcome
The United States spends more than any other developed country on health care
Costs continue to rise at an alarming rate.
Many have limited access to basic care
Characteristics Of The U.S. Health Care System
High on Cost, Unequal in Access, and Average in Outcome
Access
The ability of an individual to obtain health care services when needed
Characteristics Of The U.S. Health Care System
High on Cost, Unequal in Access, and Average in Outcome
Access
Is restricted in the US to those who:
1. Have health insurance through an
employer
2. Are covered under a government program
3. Can afford to buy insurance out-of-pocket
4. Are able to pay for services privately
High on Cost, Unequal in Access, and Average in Outcome
The absence of insurance inhibits a patient’s ability to receive well-directed, coordinated, and continuous care to primary and specialty services if referred.
Characteristics Of The U.S. Health Care System
Government as Subsidiary to the Private Sector
In most developed countries, • government plays a central role in the provision
of health care.
In the US,
• the private sector plays the dominant role because of American tradition, and the desire to limit government
Characteristics Of The U.S. Health Care System
Multiple Players and Balance of Power
The key system players have been:
– physicians
– administrators of health care institutions
– insurance companies
– large employers
– government
Characteristics Of The U.S. Health Care System
Quest for integration and accountability
In the U.S., there is:
• a drive to use primary care as the organizing hub for continuous and coordinated health services with seamless delivery
Accountability• ethically providing quality health care in an
efficient manner• safeguarding one’s own health and using
resources sensibly
Characteristics Of The U.S. Health Care System
Health Care Systems Of Other Developed Countries
Most western Europe has universal access
Models for national health systems:
1. National Health Insurance
2. National Health System
3. Socialized Health Insurance System
Look at Table 1.1, page 16
National Health Insurance Canada uses this system
Core of care delivered by private providers
Tighter consolidation of the financing, coordinated by government
Health Care Systems Of Other Developed Countries
National Health Systems
Great Britain uses this system
finance a tax-supported national health insurance program:
government manages the infrastructure for the delivery of medical care
most medical institutions are operated by government
most providers are government employees
Health Care Systems Of Other Developed Countries
Socialized Health Insurance Systems
Germany uses this style
Health care is financed through government-mandated contributions by employers and employees
Health care delivered by private providers
Sickness funds collect and pay for services
Insurance and payment is closely integrated
Delivery characterized by independent, private arrangements
Government exercises overall control
Health Care Systems Of Other Developed Countries
Conclusion The U.S. has a unique system of delivery,
therefore continuous and comprehensive care is not
enjoyed by all Americans it’s a patchwork of subsystems
No country has a perfect system
The Systems Framework is an organized approach to understanding the
components of the US health care delivery system
Slides created by:
Elizabeth A. BerzasChair and Program DirectorOur Lady of the Lake CollegeDepartment of Health Services7434 Perkins RoadBaton Rouge, LA 70808(225) [email protected]