Understanding Health Systems: The Organization of Chapter 1 Understanding Health Systems: The Organization of Health Care in the United States

Reference Table 1.1 The Development of Health Care 1850-1900: Epidemics of acute infections due to unsanitary living conditions. 1900-1941: Development of scientific medicine and the beginning of governmental and societal intervention.

Reference Table 1.1 The Development of Health Care 1941-1980: Shift from acute illnesses to chronic illnesses Classic model of illness Development of health insurance, and the explosion of medical technology.

Reference Table 1.1 The Development of Health Care 1980-present: Chronic diseases now include illnesses related to environmental hazards and working conditions, a rapid growth in costs due to technology, and an increase in governmental influence.

Social Organization 1850-1900: 1900-1941: Mid 1960’s: No formal structure. 1900-1941: The development of local hospitals and health insurance plans. Mid 1960’s: Implementation of Medicare and Medicaid insurance programs.

Three Perspectives on the American Health Care System Public policy perspective Management strategy perspective Clinical/patient perspective

Public Policy Perspective U.S. health care system is comprised of five individual sub-systems: Employment-related system Poor and uninsured system Veterans Administration system Worker’s compensation system Active duty military system

The Employment System Covers approximately two-thirds to three-quarters of the total American population. Finances one-third of health care expenditures. Collection of private employers providing health insurance in the private sector.

The Poor and Uninsured System Local governments supported by taxes and individual incomes are the sources of financing. Services are provided by safety-net providers and local hospitals in the public sector.

The Poor and Uninsured System Individuals who qualify for state Medicaid programs may obtain care in the private sector.

The Veterans Administration System National system operated by the federal government. Financed by federal tax revenues. Coverage is only available to military veterans based on length of service or service-connected disability.

The Workers’ Compensation System Care is provided to individuals who suffer from injuries or illnesses related to work environments. Insurance benefits include direct financial support for living expenses and health care. Both the employer and the employee share the cost of the insurance.

The Active Duty Military System Care is financed and provided entirely by the military system for active-duty members. Private insurance is provided to cover dependents. Dependents may receive care from hospitals and physicians in the private sector or within the military system.

Management Strategy Perspective In the 1980s Employers began to demand that insurance companies constrain the rising costs of health insurance premiums. Employers began utilizing managed care policies to reduce their costs.

Management Strategy Perspective This resulted in a major shift from a “provider-controlled” health care system to a “payer-controlled” system.

The Clinical Perspective How patients obtain care Basic service components provided to the patients Perceived quality of care and patient satisfaction

Table 1.2 The Basic Service Components Health Promotion Emergency Medical Services Ambulatory Care for Simple/Limited Conditions Ambulatory Care for Complex/Continuing Conditions Inpatient Care for Single/Limited Inpatient Conditions Inpatient Care for Complex/Multiple Inpatient Conditions Long-term care (either in-home or institutional services) Services for Social/Psychological Conditions (both inpatient and outpatient) Rehabilitation services (both inpatient and ambulatory) Dental Services Pharmaceutical Services

Table 1.3 Factors Affecting Utilization Rates Consumer Provider System Signs and symptoms Access mechanisms Contractual arrangements Beliefs Provider incentives Payment mechanisms Insurance coverage Operational systems Legal considerations Income and wealth Technology and medical information Networks and providers Information access and knowledge Referral arrangements