Chapter 1 Major Characteristics of U.S. Health Care Delivery

1. Chapter 1 Major Characteristics ofU.S. Health Care Delivery

2. 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.

3. 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. • 187.4 million Americans have private health insurance coverage

4. Subsystems of US Health Care Delivery • Managed Care • Military • Vulnerable Populations • Integrated Delivery

5. Subsystems of US Health Care 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.

6. 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.

7. 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

8. 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)

9. Subsystems of US Health Care Delivery Military • The military medical care system is • well-organized • highly integrated • comprehensive • covers preventative care

10. Subsystems of US Health Care Delivery Military • TRICARE • Financed by the military, and covers families, dependents or retired military

11. 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

12. 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.

13. 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

14. 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

15. 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

16. 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

17. 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

18. Characteristicsof 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

19. 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

20. 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: • 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

21. Characteristics Of The U.S. Health Care System • 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.

22. 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

23. 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

24. 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

25. 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

26. Health Care Systems Of Other Developed Countries • National Health Insurance • Canada uses this system • Core of care delivered by private providers • Tighter consolidation of the financing, coordinated by government

27. 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

28. 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

29. 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