Health System in USA

VIKASH RANJAN KESHRI

Moderator: Dr. P. R. Deshmukh

Outline of Presentation: Introduction Organizational structure Health Care Delivery System in US Components of US health System Major Stakeholders in the Health Care System

in US Health Financing:

Private Health Insurance Government Health Insurance:

Medicare Medicaid SCHIP Public Health System Health Care Reform in USA

Introduction: Complexity of Health System in USA Relies on a combination of governmental

action, market forces, and voluntary charitable initiatives to deliver health services.

Government

Charitable trust

Market force

Organizational Structure:

Health care delivery system in USA:

The health care delivery system in USA is in piecemeal.

Overall the system goes like this:Physician’s Office (Self-employed physician):Contractual agreement is made between group of individual and physician officePayment mode : can be direct or by reimbursement

Hospitals:large number of primary care is also provided by the hospitals only Payment mode: Direct or by reimbursement only.

Components of US Health System:

Health care

providers

Hospitals

Federal Hospital

Non – Federal

Hospital Community Hospital

Non profit For profitState – local

government

Ambulatory Care

Provider

Mental and

substance abuse care

Pharmacy service

providers

Health Maintenance Organizations (HMOs):

These are unique feature of US health system. These organizations are within the private system in US only.

Staff Model: Physicians work for HMOs. Group Model: HMO contract with separate

physicians group to provide its service. Pre- paid group practice (PPGP). IPA: Individual Practice Association.

Major Stakeholders:

Major stakeholders

Health care purchaser

Health care providers

Other supplier, policy makers/

regulator, consumers

Table.1: Health Care Expenditure pattern (2010):

Total health care expenditure 100

Health Consumption Expenditure 93.7

Personal health care 84.1

Hospital services 30.5

Professional Services 27.1

Other health residential care 4.9

Home Care 2.7

Nursing Care and continuing care 5.5

Medical Product 13.2

Govt. Admn. 1.2

Govt. Health Insurance 5.4

Govt. public health 3.1

Investment: 6.3

Research 1.8

Structure and equipment 4.5

Figure: Personal Health Care Expenditure by type of expenditure (2009).

Health Care Workforce:

Human Resource Number per 10,000

Active physician 27.4

Physician in patient care

25.4

Dentist 6

Table.2: Number of physician and Dentist per 10,000 populations (2010)

Health-Care Purchasers:

Health Care Purchaser

Private Health Insurance

Employer supported

Self supported

Government Health Insurance

Medicare

Medicaid SCHIP VA

Flow Chart: over view of health financing

Medicare:

Three basic categories of beneficiaries: Individuals age 65 and older, Individuals who are permanently and completely

disabled, and Individuals with end-stage renal disease. Four major components: PART - A PART - B PART - C PART - D

PART- A

Coverage: Coverage under part- A is mandatory for all eligible beneficiary: Short-stay hospital inpatient services, Skilled nursing facilities, Home health services, and Hospice care.Financing for part- A: Medicare Trust Fund: financed by employer and employee payroll

tax. Out of pocket deductible for hospital care. Fixed amount for an episode of care.

PART - B Covers physician care and other outpatient services. Optional benefit Beneficiaries are responsible for paying a monthly premium. beneficiaries exposed to significant out-of-pocket costs,

including deductibles, copayments, and costs for non-covered services.

Part C: Component of the Medicare program, covers an array of

managed care plans an alternative to the traditional Medicare program.

Medicare +Choice program.Part – D: Coverage for outpatient prescription drugs. As part of the Medicare Modernization Act of 2003 and Took effect during 2006.

  Medicare Age > 65 yrs. : Medicare 22.1 % Medicaid 8.8%

Employee insured plan 32.7 %

Medigap 21.5 %

Medicare free for service 14.9%

total population covered by Medicare

47.1 million

Free for all coverage 35,360

Table.3: Medicare and Medicaid coverage for age 65 yrs. and above.

Medicaid: Single largest health-care program in the country. Jointly financed and administered by the federal government and individual

state governments. Beneficiary: Poor, Elderly, Disabled, Children, Pregnant Women and Parents of young childrenMinimum services covered: Inpatient and outpatient medical care, Physician services, Laboratory and imaging services, Family planning services, Mental health services, Early childhood diagnostic screening and treatment services, and Selected long-term care services including nursing home care and home

health care.Optional services include: rehabilitation care, dental care, and home and community-based long-term care services.

Table.3: Medicaid coverage on the basis of eligibility in year 2009

Total beneficiaries 56.0 Million

Aged 65 or above 6.5%

Blind or disabled 14.0%

Adult in the family of dependent children

22.6%

Children < 21 years 48.4%

Others 8.55%

Overall Medicaid coverage:

Figure: Health insurance coverage among children < 18 years of age.

SCHIP: State Children’s Health Insurance Program Started in 1997. For low-income children not eligible for the traditional Medicaid

program. uninsured children who reside in families with incomes below 200% of

the FPL or whose family has an income 50% higher than the state’s Medicaid eligibility threshold.

Jointly financed and administered by the federal government and individual state governments.

Veteran’s Administrations: Federally administered program for veterans of the military. Health care is delivered in government-owned VA hospitals and clinics.

Private Health Insurance: Employer-sponsored insurance: Principle mode Part of the benefits package for employees. Administration: Private companies, both for-profit (e.g. Aetna, Cigna) and non-for-profit

(e.g. Blue Cross/Blue Shield). Self-Insured Company: Pay for all health care costs incurred by employees directly (general

motors). Private non-group (individual market): Population that is self-employed or retired.

USA: Public Health System:

Public Health’s Three Core Functions: (as defined by IOM) Assurance Policy Development AssessmentThe Ten Essential Services: Based on the three core principles, ten essential

services has been defined:

Unique feature of US public health system: Council on Linkages between Public Health

Practice and Academia: public health practice is “de-coupled” from its academic base to facilitate additional activities that would enhance the

practice/academic connection

Organizations under the Public Health System: The current operational arms of the PHS include: National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), Indian Health Service (IHS), Food and Drug Administration (FDA), Agency for Toxic Substances and Disease Registry (ATSDR) (administered by

the CDC), and Substance Abuse and Mental Health Administration (SAMHA)

The Ten Essential Services: The three core functions were further expanded to a list of Ten Essential

Community Health Services that would more clearly define the services communities need in order to achieve high levels of healthfulness.6 Those Ten Essential Services are:

Monitor health status to identify community health problems. Diagnose and investigate health problems and health hazards in the

community. Inform, educate, and empower people about health issues. Mobilize community partnerships to identify and solve health problems. Develop policies and plans that support individual and community health

efforts. Enforce laws and regulations that protect health and ensure safety. Link people to needed personal health services and ensure the provision of

health care when otherwise unavailable. Ensure a competent public health and personal health workforce. Evaluate effectiveness, accessibility, and quality of personal and

population-based health services. Research for new insights and innovative solutions to health problems.

 THE STATE PUBLIC HEALTH ROLE:

Assessment of the health needs in the state based on statewide data collection:

Assurance of an adequate statutory base for health activities in the state Establishment of statewide health objectives, delegating power to locals as

appropriate and holding them accountable Assurance of appropriate organized statewide effort to develop and

maintain essential, personal, educational, and environmental health services;

Provision of access to necessary services; and solution of problems inimical to health

Guarantee of a minimum set of essential health services Support of local service capacity.

Health Care Reform: 2010 (Obama Care)

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