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

2. © 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

3. © 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

4. 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.

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

6. 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

7. 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

8. 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

9. 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

10. 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

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

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.
© 2012 Jones and Bartlett Publishers

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.
© 2012 Jones and Bartlett Publishers

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.
© 2012 Jones and Bartlett Publishers

16. 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

17. 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.

18. 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

19. 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

20. 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

21. 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.

22. © 2010 Jones and Bartlett Publishers

23. 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

24. 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.

25. 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.

26. 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

27. 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

28. 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.

29. 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.

30. 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.

31. 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.

32. 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

33. 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

34. 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.

35. 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

36. 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

37. 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

38. 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

39. © 2010 Jones and Bartlett Publishers

40. 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.

41. 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.

42. 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

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

44. 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.

45. © 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

46. © 2010 Jones and Bartlett Publishers

47. © 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