us health care system overview 1

1.Chapter 1Major Characteristicsof U.S. Health Care Delivery

The United States has a unique system of health care delivery.

The US health care delivery system is complex and massive.

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.

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 arenotentitled to routine and basic health care services.

187.4 million Americans have private health insurance coverage,

35.2 million Medicare beneficiaries, and

31.5 million Medicaid recipients.

Health insurance can be bought from:

1,000 health insurance companies

70 BlueCross/BlueShield plans

The managed care sector includes approximately:

540 licensed health maintenance organizations (HMOs)

925 preferred provider organizations (PPOs)

Managed Care

Military

Vulnerable Populations

Integrated 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.

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.

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

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)

Military

The military medical care system is

well-organized

highly integrated

comprehensive

covers preventative care

Military

TRICARE

Financed by the military, and covers families, dependents or retired military

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

Military

The mission of the VA health care system:

Provide medial care, education and training, research, contingency support and emergency management for the Department of Defense medical care system.

Military

The VA health care system has:

over 1,100 sites

172 hospitals

206 counseling centers

40 residential care facilities

73 home health programs, and

provides care to 3.6 million

Military

The VA:

Budgets over $20 billion

Employs over 182,000

Affiliates with

13,000 physicians

53,000 nurses

3,500 pharmacists

Military

The VA is:

organized into 22 geographically-distributed Veterans Integrated Service Networks (VISN)

Each VISN

coordinates its own services

receives federal funds

Particularly the poor, uninsured, minorities and immigrants

live in disadvantaged communities and receive care from safety net providers.

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

Integrated Delivery

The hallmark of the US health care industry:

to form integrated delivery systems (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

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

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

Government as Subsidiary to the Private Sector

Market Justice vs. Social Justice

Multiple Players and Balance of Power

Quest for Integration and Accountability

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

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

Technology has had successful interventions, but is overused

This prohibits

employers extending benefits to part-time workers and

insurers lowering premiums

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

Access

The ability of an individual to obtain health care services when needed

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

The absence of insurance inhibits a patients ability to receive well-directed, coordinated, and continuous care to primary and specialty services if referred.

Under national health care programs,

patients have varying degrees of choice in selecting providers

true free market forces are virtually nonexistent.

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

For the health care market to be free,

unrestrained competition must occur among providers, on the basis of price and quality

A free market requires that patients have

information about the availability of various services

In a free market, patients as consumers must:

directly bear the cost of services received.

make decisions about the purchase of health care services

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

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.

Multiple Players and Balance of Power

The key system players have been:

physicians

administrators of health care institutions

insurance companies

large employers

government

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 ones own health and using resources sensibly

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

National Health Insurance

Canada uses this system

Core of care delivered by private providers

Tighter consolidation of the financing, coordinated by government

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

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

Systems consist of:

a set of interrelated and interdependent components designed to achieve some common goals

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

The framework outlines:

System Foundations

System Resources

System Processes

System Outcomes

System Outlook

Look at Figure 1.2, page 18

The U.S. has a unique system of delivery, therefore

continuous and comprehensive care is not enjoyed by all Americans

its 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

Elizabeth A. Berzas

Chair and Program Director

Our Lady of the Lake College

Department of Health Services

7434 Perkins Road

Baton Rouge, LA 70808

(225) 786-1706

[email_address]

www.ololcollege.edu

us health care system overview 1

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