US health care system overview 1

1. Chapter 1
Major Characteristics
of
U.S. Health Care
Delivery

2. Introduction
The United States has a unique system of
health care delivery.
The US health care delivery system is
complex and massive.

3. 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.

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. Introduction
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)

6. Subsystems of
US Health Care Delivery
•Managed Care
•Military
•Vulnerable Populations
•Integrated Delivery

7. 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.
Subsystems of
US Health Care Delivery

8. 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.
Subsystems of
US Health Care Delivery

9. 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
Subsystems of
US Health Care Delivery

10. 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)

11. Subsystems of
US Health Care Delivery
Military
The military medical care system is
well-organized
highly integrated
comprehensive
•covers preventative care

12. Subsystems of
US Health Care Delivery
Military
TRICARE
Financed by the military, and covers
families, dependents or retired
military

13. Subsystems of
US Health Care Delivery
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

14. Subsystems of
US Health Care Delivery
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.

15. Subsystems of
US Health Care Delivery
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

16. Subsystems of
US Health Care Delivery
Military
The VA:
Budgets over $20 billion
Employs over 182,000
Affiliates with
13,000 physicians
53,000 nurses
3,500 pharmacists

17. Subsystems of
US Health Care Delivery
Military
The VA is:
organized into 22 geographically-distributed
Veterans Integrated Service Networks (VISN)
•Each VISN
–coordinates its own services
–receives federal funds

18. 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.

19. 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

20. 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

21. 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

22. 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
Characteristics Of The U.S.
Health Care System

23. 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
•Look at Exhibit 1.1, page 8

24. 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

25. 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

26. Characteristics Of The U.S.
Health Care System
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

27. Characteristics Of The U.S.
Health Care System
High on Cost, Unequal in Access, and
Average in Outcome
Access
The ability of an individual to obtain
health care services when needed

28. Characteristics Of The U.S.
Health Care System
High on Cost, Unequal in Access, and
Average in Outcome
Access
Is restricted in the US to those who:
2.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

29. High on 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

30. 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

31. 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

32. 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

33. Imperfect Market Conditions
A free market requires that patients have
information about the availability of various
services
Characteristics Of The U.S.
Health Care System

34. 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
Characteristics Of The U.S.
Health Care System

35. 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

36. 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.
Characteristics Of The U.S.
Health Care System

37. Multiple Players and Balance of Power
The key system players have been:
–physicians
–administrators of health care institutions
–insurance companies
–large employers
–government
Characteristics Of The U.S.
Health Care System

38. 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
Characteristics Of The U.S.
Health Care System

39. 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
Look at Table 1.1, page 16

40. 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

41. 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

42. 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
Health Care Systems Of Other
Developed Countries

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. The framework outlines:
System Foundations
System Resources
System Processes
System Outcomes
System Outlook
Look at Figure 1.2, page 18
Systems Framework

46. 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

47. Slides created by:
Elizabeth A. Berzas
Chair and Program Director
Our Lady of the Lake College
Department of Health Services
7434 Perkins Road
Baton Rouge, LA 70808
[phone]
[email protected]
www.ololcollege.edu