Developed through the APTR Initiative to Enhance Prevention and Population Health Education in collaboration with the Brody School of Medicine at East Carolina University with funding from the Centers for Disease Control and Prevention ID: 731700
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Slide1
Module 5:Healthcare Systems
Developed through the APTR Initiative to Enhance Prevention and Population Health Education in collaboration with the Brody School of Medicine at East Carolina University with funding from the Centers for Disease Control and Prevention
US Healthcare Delivery SystemsSlide2
Acknowledgments
This education module is made possible through the Centers for Disease Control and Prevention (CDC) and the Association for Prevention Teaching and Research (APTR) Cooperative Agreement, No. 5U50CD300860. The module represents the opinions of the author(s) and does not necessarily represent the views of the Centers for Disease Control and Prevention or the Association for Prevention Teaching and Research. APTR wishes to acknowledge the following individuals that developed this module:
Joseph Nicholas, MD, MPH
University of Rochester School of Medicine
Anna Zendell, PhD, MSW
Center for Public Health Continuing Education
University at Albany School of Public Health
Mary Applegate, MD, MPH
University at Albany School of Public Health
Cheryl Reeves, MS, MLS
Center for Public Health Continuing Education
University at Albany School of Public HealthSlide3
Presentation ObjectivesList the major sectors of the US healthcare system
Describe interactions among elements of the healthcare system, including clinical practice and public healthDescribe the organization of the public health system at the federal, state, and local levelsDescribe the impact of the healthcare system on special populations
Describe roles and interests of
oversight entities
on US health system policySlide4
System OverviewSlide5
Goals of Healthcare Delivery SystemSlide6
Questions to ConsiderWho currently utilizes health care in the US?Where do most healthcare encounters occur?What is the reason for most encounters?
What are the different models for organizing, funding and regulating these encounters?How do public health and clinical practice influence one another? Slide7
System Demands 1.2 billion ambulatory visits per year (2008)Children - routine health check and respiratory infections
Young women - pregnancy, gynecologic careAdults (both sexes) - hypertension, ischemic heart disease, and diabetes mellitus35 million hospital discharges (2006)Average length of stay - 4.8 days46 million procedures performed
National Center for Health Statistics 2008Slide8
Overview of Public Health SystemSlide9
Role of Public HealthFederalRegulation of commerceControl entry of persons to USControl inspection/entry of products to US and across state lines
Funding of public health programsProvision of care for special populationsCoordination of federal agenciesSlide10
Community health assessmentPublic health policy developmentAssurance of public health service provision to communitiesContinuity between federal public and local public healthConduit for funding
Linkage of resources to needsRole of Public HealthStateSlide11Slide12
May be city and/or county-basedProvide mandated public health servicesEnact and enforce public health codes as mandated by state and federal officialsMust meet minimum threshold of state standards
May be more rigorous than state standardsRole of Public HealthLocalSlide13
Vital statisticsCommunicable disease controlMaternal and child healthEnvironmental healthHealth education
Public health laboratoriesLocal Public Health FunctionsSlide14
Clinical Medicine and Public HealthClinical MedicinePatient-focusedDiagnosis and treatmentMedical care paradigm
Public HealthPopulation-focusedDisease prevention and health promotionSpectrum of interventionsSlide15
Healthcare System SectorsSlide16
Types and Settings of Services
Shi & Singh 2008Types of Healthcare Services
Delivery
Settings
Preventive Care
Public
Health Programs
Community Programs
Personal Lifestyles
Primary Care
Physician
Office/Clinic
Self-Care
Alternative Medicine
Specialized Care
Specialist Clinics
Chronic Care
Primary Care Settings
Specialist Provider
Clinics
Home Health
Long-term Care Facilities
Self-Care
Alternative MedicineSlide17
Types and Settings of Services (2)
Types of Healthcare ServicesDelivery SettingsLong-term CareLong-term Care Facilities
Home Health
Sub-Acute Care
Special Sub-Acute
Units (
Hospital, Long-term Care Facilities
)
Home Health
Outpatient Surgical Centers
Acute Care
Hospitals
Rehabilitative
Care
Rehabilitation Departments (
Hospital, Long-Term Care
Facilities)
Home Health
Outpatient Rehabilitation Centers
End-of-Life
Care
Hospice
Services
Shi & Singh 2008Slide18
Typically address acute, chronic, preventive/wellness issuesCoordinate specialty care when neededProviders are typically generalists (MD/DO/NP/PA)Primary care specialties : Family Medicine, General Internal Medicine, Pediatrics, Obstetrics-Gynecology
Develop ongoing patient-provider relationshipMultiple settings: provider offices, clinics, schools, colleges, prisons, worksites, home, mobile vansPrimary CareSlide19
Secondary CareTypically subspecialty care focused on a particular organ system or disease processAvailable in most communitiesIncludes common inpatient and outpatient services
Subspecialty office careInpatient care including emergency care, labor and delivery, intensive care, diagnostic imagingSlide20
Tertiary Care Consultative subspecialty careTypically provided at large regional medical centersCharacterized by advanced technology and high volume of procedures
Tertiary care sites usually serve as major education sites for students in a variety of health professionsSlide21
Prevention Triangles
Population Oriented Prevention
Clinical Preventive Services
Primary Medical Care
Secondary Medical Care
Tertiary Medical Care
Relative
Investment
Tertiary
Prevention
Secondary
Prevention
Primary
Prevention
2% of $$Slide22
Current System ComponentsPersonnelHealthcare institutions
US Public Health Service Commissioned CorpsDrug and device manufacturersEducation and researchSlide23
PersonnelNursesPhysicians (MD/DO)
NP,PA, midwivesPharmacistsDentistsSeveral million ancillary personnel
80% involved in direct healthcare provision
Therapists, social workers, lab technicians
National Center for Health Statistics 2004Slide24
PersonnelProvider Practice OrganizationsTraditional solo practitioner model is fadingMost providers join larger groups
Private, physician-owned groupsHealth system owned groups (networks)Health maintenance organizationsPreferred provider organizationsSlide25
Healthcare InstitutionsHospitalsPrivate, community hospitals Not for profits are most common
Many are religiously affiliatedPrivate, for profitPublic (state or local government)Psychiatric hospitalsAcademic medical centers
VA and military centersSlide26
Other Major Healthcare InstitutionsLong term care facilitiesNursing homes/skilled nursing facilities
Assisted living facilities*Enhanced care facilities*Adult homes*
Rehabilitation facilities
Physical rehabilitation
Substance abuse facilities
*These residential long-term care facilities are not really healthcare institutions but commonly referred to as such. Slide27
US Public Health Service Commissioned Corps6,600 full time clinical and public health professionalsProvide primary care in underserved areas
Staff domestic and international public health emergenciesWork in research, administrative and public health capacities in a number of federal agenciesSlide28
Pharmaceuticals and DevicesLarge industry with major impact on cost and policy$234 billion in 2008Growing rapidly with the passage of Medicare D (prescription benefit)
Regulated by Food and Drug AdministrationHartman et al 2010Slide29
Education and ResearchPublic/Private funding mix supports undergraduate nursing, medical and physician assistant programsPublic funding of Graduate Medical Education
US does not actively manage specialty choice or distribution of its physician workforceGovernment is major funder for basic medical researchIndustry is major funder for clinical trials of drugs, and devices and continuing medical educationSlide30
Healthcare OversightSlide31
Healthcare Regulation WebDiverse set of regulatorsGovernment (state, federal, local)Insurers
HospitalsPrivate accrediting bodiesProfessional societiesSlide32
Goals of Healthcare Delivery SystemSlide33
State RegulationMost healthcare regulation comes from statesLicensure and oversight of medical facilities and providersControl distribution of services through
certificate of need processRegulate insurance coverageMandate minimum standardsRegulate cost, scope of coverage and exclusion criteriaSlide34
Certificate of Need (CON)PurposeCost containmentPrevent unnecessary duplication of health care
Ensure high quality health services Accomplishes this through many rolesExtensive review processSlide35
Federal RegulationRegulatory power derived from federal status as the major payor in most systems (Medicare, Medicaid)Reimbursement is increasingly tied to compliance with federal standardsDepartment of Health and Human Services (DHHS) is the major federal actor in healthcare regulationSlide36
Major Federal Healthcare System Regulatory AgenciesSlide37
Contract with physicians/hospitals to encourageQualityCost controlMarket shareSet standardsAudit providers and institutionsAdjust payments accordingly
Regulators
InsurersSlide38
Credential physicians, physician assistants, midwives, nurses, other healthcare staffHospital credentialing often necessary for malpractice insurance eligibilityRegular review of medical staff for quality, professional conduct and practice standards
RegulatorsHospitalsSlide39
JCAHO (Joint Commission on Accreditation of Healthcare Organizations)Accredits hospitalsPrivate organization of member hospitalsNCQA (National Committee for Quality Assurance)
Accredits managed care plansPrivate organization representing employers/purchasersSpecialty OrganizationsSpecific certifications (bariatric surgery centers, Baby Friendly USA)
Regulators
Private Accrediting OrganizationsSlide40
Professional SocietiesHistorically the major regulator of healthcare delivery until increasing influence of government and insurance industriesStill influential in determining acceptable professional practice standards, and contributing to regulatory policySlide41
Professional Impairment Regulatory System ResponseMost common impairments
Substance abuse/dependencyMental illnessAging-related impairments a growing problemTrend toward treatment vs. sanctionSlide42
Special PopulationsSlide43
VeteransUnique health care infrastructureInter-generational health care needs
Health/public health considerations War-related injuries Chemical exposureHomelessness
Post traumatic stress disorder
Prisoners of warSlide44
Indian Health ServiceCreated through treaties between US government and Indian tribesEligibility for US benefits and programs
Contract Health Services (CHS) to supplementConsiderations for American IndiansSafe water and sewageInjury mortality rate 2-4x other AmericansSlide45
StudentsK-12 Student Health CentersMedical, psychosocial, preventive care for all
Age appropriate health educationCollege Student Health CenterMedical and preventive care for allCampus health emergenciesSlide46
Correctional Facilities Privatization and telemedicine are growing trends to meet prisoner healthcare needsUnique considerations
Injuries, infectious diseases, and substance abuse very prevalent> 50% of inmates suspected to have mental illnessAging in prisonsMust address barriers to health care – secure escortSlide47
Intellectual/Developmental Disabilities Considerations Intellectual/Developmental Disabilities (I/DD)-specific clinic or integrated health care
Consent capacitySurrogate Decision Making CommitteesGuardianshipDiagnostic, treatment challengesCaregiver perspectives on health concernsSlide48
Global Perspective on Healthcare SystemsSlide49
Evaluation of US Healthcare SystemStrengthsAdvanced diagnostic and therapeutic technologyTimely availability of subspecialists and proceduresSlide50
Evaluation of US Healthcare SystemWeaknessesLimited access to multiple underserved populationsHigh cost with marginal population outcomes
Fragmentation of careInsufficient primary care workforceHighly bureaucratic/large administrative costsMisaligned incentivesSlide51
Healthcare System Models Socialized Medicine(United Kingdom Model)
Government is dominant service payor and providerFund through taxesUniversal accessIn US, this is model for Veterans Affairs (VA)
Socialized Insurance
(
Bismark
Model)
Private insurance is dominant
payor
Fund via employers and/or employees
Need additional mechanisms for universal access
In US, this is primary model for citizens <65 yearsSlide52
Healthcare System Models National Health Insurance(Canadian Model)
Government is dominant payorProviders, hospitals are a mix of public/privateFunded through taxesUniversal accessIn US, this is the model for Medicare and Medicaid
Out of Pocket Model
No organized system for payment
No pooling of risk
Access limited
In US, this is the model faced by large numbers of uninsuredSlide53
Systems ComparisonsSlide54
Outcomes - Life ExpectancySlide55
Current Trends Medical TourismConcierge MedicinePhysician retainer fee
Executive healthcareSlide56
Current Trends - Attempts to Expand AccessInsurance/Payment reformsLess exclusion, access to larger pools
Offering less comprehensive benefits/limiting choiceShifting more costs to consumersHigh deductible plansHealth savings accountsSubsidize private insuranceMedicaid eligibility expansion
Funding of community health centersSlide57
Federally Qualified Health CentersProvide primary health care access to persons regardless of ability to payIncludes mental health, dental, transportation, translation, education
Accept insuranceGrant funded by HRSA, enhanced payments from Medicare/MedicaidTypesCommunity health centersMigrant health centersHealthcare for the Homeless Programs
Public Housing Primary Care ProgramsSlide58
System at the Brink?Accelerating healthcare costs promise to swamp access/quality issuesWorkforce and hospitals are geared to provide expensive, high-tech, tertiary care for the foreseeable futureAging population living longer with more co-morbiditiesSlide59
Impending Demographic TsunamiSlide60
Paradigm Shift in Healthcare Delivery
Trends and Directions in Healthcare DeliveryIllness
Wellness
Acute Care
Primary Care
Inpatient
Outpatient
Individual
Health
Community Well-Being
Fragmented Care
Managed Care
Independent Institutions
Integrated Settings
Service Duplication
Continuum
of ServicesSlide61
SummaryUS healthcare system is a large patchwork of public and private programsPublic funds account for nearly 50% of healthcare spending
Cost is rapidly becoming dominant policy issueQuality and access remain significant policy issues Slide62
Collaborating InstitutionsDepartment of Public Health
Brody School of Medicine at East Carolina UniversityDepartment of Community & Family Medicine Duke University School of MedicineSlide63
Advisory CommitteeMike Barry, CAE
Lorrie Basnight, MDNancy Bennett, MD, MSRuth Gaare Bernheim, JD, MPH
Amber Berrian, MPH
James
Cawley
, MPH, PA-C
Jack Dillenberg, DDS, MPH
Kristine
Gebbie
, RN,
DrPH
Asim Jani, MD, MPH, FACP
Denise Koo, MD, MPH
Suzanne Lazorick, MD, MPH
Rika Maeshiro, MD, MPH
Dan Mareck, MD
Steve McCurdy, MD, MPH
Susan M. Meyer, PhD
Sallie
Rixey
, MD,
MEd
Nawraz Shawir, MBBSSlide64
APTRSharon Hull, MD, MPH
PresidentAllison L. Lewis Executive DirectorO. Kent Nordvig,
MEd
Project Representative