Embed Size (px)
Citation preview
U.S. Health Care Delivery:
An Overview
Objectives
• Gain broad understanding of how health care is delivered in the United States
• Learn main characteristics of U.S. health care delivery system
• Recognize differences between U.S. health care delivery system and national health programs of most developed countries
• Learn of U.S. health care delivery subsystems
• What is health care delivery?
• What is a health care delivery system?
U.S. Health Care Delivery: A Systems Framework
• Health care delivery in the United States– Is based upon a foundation of historical, cultural,
social, and economic factors– Consists of a logical arrangement of various
interrelated and interdependent components– Demonstrates a progression from “inputs” to
“outputs”– Despite appearances, it is not an accident!
Outpatient & Primary Care
Inpatient & Acute Care
Long-term & Post-acute
Care
Structure & Processes
Human Resources
Technology
Financing
CostAccessQuality
Policy & Reform
OutputsInputs
Managed Care & Health Networks
Underserved Populations
U.S. Health Care Delivery: A Systems Framework(Adapted from Shi & Singh, 2013)
Cultural, Social, & Economic Factors
System Foundations
Historical FactorsFuture Trends
U.S. Health Care System:The Main Characteristics
• The U.S. health care system is unique in comparison to the health care systems of other developed countries
• Ten main areas of distinction
❶ No central governing agency,Little integration and coordination
• Not centralized• Complex and costly• A variety of payment, insurance, and delivery
mechanisms• Large role of private sector• Limited but important role of federal & state
governments
Health Expenditures by OECD Country(Percent of GDP)
5.75.96.46.8
6.87.37.47.67.78.18.28.48.58.7
8.78.98.99.19.2
9.39.69.8
9.89.910
.1
10
.1
10
.2
10
.4
10
.8
11.0
16
.0
0
5
10
15
20
Tu
rke
yM
exi
coP
ola
nd
Cze
ch …
Ko
rea
Lu
xem
bour
g3
Hu
ng
ary
Ire
lan
dS
lova
k …Ja
pa
nF
inla
nd
Un
ited
…S
pa
inA
ust
ralia
Italy
OE
CD
No
rwa
yS
we
de
nN
ew
Ze
ala
nd
2Ic
ela
nd
Gre
ece
De
nm
ark
Ne
the
rlan
ds1
Po
rtu
ga
lA
ust
riaC
an
ad
aB
elg
ium
1G
erm
an
yS
witz
erla
nd
Fra
nce
Un
ited
Sta
tes
Public expenditure Private expenditure
Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).
❷ Technology driven,Focused on acute care
• Center of medical research & innovation– Creates growth in demand for new services– Negative outcomes accompany benefits
• Is the latest or most high-tech solution always the best?
• Would increased emphasis on primary care prevent acute conditions requiring high-tech intervention?
❸ High on cost,Unequal in access,Average in outcome
• The U.S. spends more than any other developed country on health care
• Despite rising expenditures, many residents have limited access to basic care
• Despite rising expenditures, the U.S. lags behind other developed nations in numerous population health measures
Health Expenditures by OECD Country
Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).
Health Expenditure Growth Trends(% of GDP)
Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).
Life Expectancy vs. Health Spending
Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).
❹ Imperfect market conditions
• The payer is not always the patient• Competition is restrained• Patients are not always well-informed• Information is difficult to obtain• Patients do not directly bear service costs• Patients’ ability to make decisions is limited
❺ Government as subsidiary toprivate sector
• Dominant private sector– Built upon American traditions
• Government spending fills in the gaps– Environmental protections– Support for research & training– Care for vulnerable populations
❻ Market justice vs. social justice:Conflict throughout health care
• U.S. health care system involves a fusion of these two principles
• Differing views of how to distribute care– Ability vs. need
• What might be the consequences of a system that favors market justice? Or social justice?
❼ Multiple players & Balance of power
• U.S. health care involves multiple players• Self-interests of players are often at odds• What might be the consequences of a system
with competing interests and voices?– Good? Bad?
• Is reform possible?
❽ Quest for integration & accountability
• Efforts in the U.S. to promote primary care as the organizing hub for continuous, coordinated, and comprehensive services
• Emphasizes patient-provider relationships as a means to improve individual and population
• Patient-provider relationships also require accountability
❾ Access to health care services isselectively based on insurance
• Access is granted to individuals who:– Have health insurance through employers– Are covered under government programs– Can afford to buy insurance with private funds– Can pay for services privately
• What are options for the uninsured?
❿ Legal risks influence practice behaviors
• “Litigious society”• Private health care providers are increasingly
becoming more susceptible to litigation– Risk of malpractice lawsuits– Costs of time, money, reputation, etc.– Defensive medicine a way to avoid litigation
Comparing to Health Care Systems of Other Developed Countries
• National health care programs with universal access
• Three basic national health care system models– National Health Insurance (e.g., Canada)– National Health System (e.g., Great Britain)– Socialized Health Insurance System (e.g.,
Germany)
Models of Health Care Delivery
• Bismarck Model– Sickness funds financed jointly by employers &
employees• Beveridge Model
– Health care provided & financed by government through taxes
• National Health Insurance Model– Government insurance purchases care from private
providers• Out of Pocket Model
– If you have the resources, you can pay for care
U.S. Health Care Delivery Subsystems
• In contrast to a universal health care delivery system, multiple subsystems have developed to comprise the U.S. health care delivery system– Managed care– Military– Vulnerable populations– Integrated delivery
U.S. Health Care Delivery Subsystems
• Managed care– Developed to contain health care costs &
expenditures– Seeks to achieve efficiency by integrating basic
functions of health care delivery– Employs mechanisms to control or manage
utilization of medical services– Determines the price at which services are
purchased and how much providers are paid– Most dominant health care delivery system in U.S.
U.S. Health Care Delivery Subsystems
• Military– Available free-of-charge to active-duty military
personnel– Well-organized, highly integrated system– Combines public health with medical services– In general, the military medical care system
provides high-quality health care
U.S. Health Care Delivery Subsystems
• Vulnerable populations– Poor, uninsured, minority or immigrant status– Live in geographically or economically
disadvantaged communities– Receive care from “safety net” providers– Without safety net providers, patients have to
forego care or seek care in hospital emergency departments (if one exists nearby)
– Subsystem faces enormous pressure
U.S. Health Care Delivery Subsystems
• Integrated delivery– The hallmark of U.S. health care industry over the
past decade – and becoming larger– Organizational integration to form integrated
delivery systems (IDS) or networks– Strategic linkages among hospitals, physicians, and
insurers– Objective: have one health care organization
deliver a range of services
U.S. Health Care Delivery Subsystems
• Long Term Care– Medical and nonmedical care that is provided to
individuals who are chronically ill or who have a disability.
– Health care and support services for daily living– Not covered by Medicare– LTC insurance is offered separately, but it can be
expensive– Expected to have more integration with the acute
care system
U.S. Health Care Delivery Subsystems
• Public Health System– Improve and protect community health
• Monitoring health status• Diagnosing and investigating, informing and educating
health problems and hazards• Developing policies• Enforcing laws and regulations• Assuring competent professional health workforce• Research
What We’ve Learned
• The U.S. health care delivery system is unique– Characterized by a patchwork of subsystems– Differs considerably from systems of other
developed countries– May be viewed according to a systems framework
to generally understand the various system components and features
