Chapter 1 Major Characteristics of U.S. Health Care Delivery © 2012 Jones and Bartlett Publishers

© 2012 Jones and Bartlett Publishers Introduction The United States has a unique system of health care delivery. The US health care delivery system is complex and massive. © 2012 Jones and Bartlett Publishers

© 2010 Jones and Bartlett Publishers 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. © 2010 Jones and Bartlett Publishers

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.

Subsystems of US Health Care Delivery Managed Care Military Vulnerable Populations Integrated Delivery Long-term Care Public Health © 2012 Jones and Bartlett Publishers

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. © 2012 Jones and Bartlett Publishers

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. © 2012 Jones and Bartlett Publishers

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” © 2012 Jones and Bartlett Publishers

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). © 2012 Jones and Bartlett Publishers

Subsystems of US Health Care Delivery Military -The military medical care system is well-organized. highly integrated. Comprehensive. -Covers preventative care © 2012 Jones and Bartlett Publishers

Subsystems of US Health Care Delivery Military -TRICARE Financed by the military, and covers families, dependents or retired military. © 2012 Jones and Bartlett Publishers

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. © 2012 Jones and Bartlett Publishers

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. © 2012 Jones and Bartlett Publishers

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. © 2012 Jones and Bartlett Publishers

Subsystems of US Health Care Delivery Long-term Care Consists of medical and nonmedical care that is provided to individuals who are chronically ill or who have a disability. By 2020, more than 12 million Americans are projected to require LTC. © 2012 Jones and Bartlett Publishers

Subsystems of US Health Care Delivery Public Health 1. Monitoring health status to identify and solve community health problems. 2. Diagnosing and investigating health problems and hazards. 3. Informing and educating people about health problems and hazards. 4. Mobilizing the community to solve health problems. 5. Developing policies to support individual and community health efforts.

Subsystems of US Health Care Delivery Public Health 6. Enforcing laws and regulations to support health safety. 7. Providing people with access to necessary care. 8. Assuring a competent and professional health workforce. 9. Evaluating the effectiveness, accessibility, and quality of personal and population-based health services. 10. Performing research to discover innovative solutions to health problems. © 2012 Jones and Bartlett Publishers

Key Characteristics of the U.S. Health Care System 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 © 2012 Jones and Bartlett Publishers

Key Characteristics of the U.S. Health Care System Government as Subsidiary to the Private Sector Market Justice vs. Social Justice Multiple Players and Balance of Power Quest for Integration and Accountability Access to Healthcare Selectively Based on Insurance Legal Risk Influences Practice Behavior © 2010 Jones and Bartlett Publishers

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.

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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. © 2012 Jones and Bartlett Publishers

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 in 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 in Cost, Unequal in Access, and Average in Outcome -Access The ability of an individual to obtain health care services when needed. © 2012 Jones and Bartlett Publishers

Characteristics Of The U.S. Health Care System High in 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. © 2012 Jones and Bartlett Publishers

Characteristics Of The U.S. Health Care System High in 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 Imperfect Market Conditions -Under national health care programs, Patients have varying degrees of choice in selecting providers. True “free market” forces are virtually nonexistent.

Characteristics Of The U.S. Health Care System Imperfect Market Conditions -In a free market, Multiple patients (buyers) and providers (sellers) act independently. Patients should be able to choose their provider based on price and quality.

Characteristics Of The U.S. Health Care System Imperfect Market Conditions -For the health care market to be free, Unrestrained competition must occur among providers, on the basis of price and quality.

Characteristics Of The U.S. Health Care System Imperfect Market Conditions -A free market requires that patients have Information about the availability of various services. © 2012 Jones and Bartlett Publishers

Characteristics Of The U.S. Health Care System Imperfect Market Conditions -In a free market, patients as consumers must: Directly bear the cost of services received. Make decisions about the purchase of health care services. © 2012 Jones and Bartlett Publishers

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 Market Justice and Social Justice: Conflict Throughout Health Care -Market justice and social justice are: Two contrasting theories that govern the production and distribution of health care services in the United States. © 2012 Jones and Bartlett Publishers

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 © 2012 Jones and Bartlett Publishers

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. © 2012 Jones and Bartlett Publishers

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 © 2012 Jones and Bartlett Publishers

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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.

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 is 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. © 2012 Jones and Bartlett Publishers

Systems Framework Systems consist of: -A set of interrelated and interdependent components designed to achieve some common goals.

Systems Framework The systems framework: -Explains the structure of health care services in the U.S. based on the foundations. -Provides a logical arrangement of various components. -Demonstrates a progression from inputs to outputs.

© 2012 Jones and Bartlett Publishers Systems Framework The framework outlines: -System Foundations -System Resources -System Processes -System Outcomes -System Outlook Look at Figure 1.2, page 25 © 2012 Jones and Bartlett Publishers

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© 2012 Jones and Bartlett Publishers 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. © 2012 Jones and Bartlett Publishers