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Chapter 1 . Major Characteristics . of U.S. Health Care Delivery. © 2012 Jones and Bartlett Publishers. Introduction. The United States has a unique system of health care delivery.. The US . health care . ID: 748251

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Chapter 1
Major Characteristics
of U.S. Health Care Delivery
Introduction
The United States has a unique system of health care delivery.
The US
health care
delivery system is complex and massive.
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.
IntroductionIn 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.
Subsystems
of US Health Care Delivery
Managed Care
Military
Vulnerable Populations
Integrated Delivery
Long-term Care
Public Health
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
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:
A
n
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
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
”
Subsystems of US Health Care Delivery
0
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.
C
ertain
uniformed nonmilitary services such as
-The
Public Health Services and
-The
National Oceanographic and Atmospheric Association (NOAA
).
Subsystems of US Health Care Delivery
1
Military
-The
military medical care system is
well-organized.
highly
integrated.
Comprehensive.
-Covers
preventative care
Subsystems of US Health Care Delivery
2
Military
-TRICARE
Financed by the military, and covers families, dependents or retired
military.
Subsystems of US Health Care Delivery
3
Military
The VA health care system
-Is available
to retired
veterans.
-Focuses
on
H
ospital
, mental health and long-term
care.
-Is
one of the largest and oldest (1946) organized health systems in the
world.
Subsystems of US Health Care Delivery
4
Subsystems of US Health Care DeliveryMilitaryThe mission of the VA health care system:-Is to provide medial care, education and training, research, contingency support and emergency management for the Department of Defense medical care system.
5
Subsystems of
US
Health Care Delivery
Military
The VA:
-Budgets
over $40 billion
-Employs
over 280,000
6
Military
The VA is:
-Organized
into 23 geographically-distributed Veterans Integrated Service Networks (VISN
).
-Each
VISN
Coordinates
its own
services.
R
eceives
federal
funds.
Subsystems of US Health Care Delivery
7
Vulnerable Populations
-Particularly
the poor, uninsured, minorities and
immigrants:
L
ive
in disadvantaged communities and receive care from “safety net” providers.
Subsystems of US Health Care Delivery
8
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.
Subsystems of US Health Care Delivery
9
Integrated DeliveryThe 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.
Subsystems of US Health Care Delivery
0
Integrated Delivery
IDS
is
-A
network of organizations that provides or arranges to provide a coordinated continuum of services to
D
efined
populations held clinically and fiscally accountable for outcomes and health
status.
Subsystems of US Health Care Delivery
1
Long-term Care
C
onsists
of medical and nonmedical care that is provided to individuals who are chronically ill or who have a disability.
By 2020, more than 12 million Americans are projected to require
LTC.
Subsystems of US Health Care Delivery
2
Public Health1. Monitoring health status to identify and solve community health problems.2. Diagnosing and investigating health problems and hazards.3. Informing and educating people about health problems and
hazards.
4. Mobilizing the community to solve health
problems.
5. Developing policies to support individual and community health
efforts.
Subsystems of US Health Care Delivery
3
Public Health
6
. Enforcing laws and regulations to support health
safety.
7. Providing people with access to necessary
care.
8. Assuring a competent and professional health
workforce.
9. Evaluating the effectiveness, accessibility, and quality of personal and population-based health
services.
10. Performing research to discover innovative solutions to health
problems.
Subsystems of US Health Care Delivery
4
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
Key Characteristics of the U.S. Health Care System
5
Government as Subsidiary to the Private SectorMarket Justice vs. Social JusticeMultiple Players and Balance of PowerQuest for Integration and AccountabilityAccess to Healthcare Selectively Based on Insurance Legal Risk Influences Practice Behavior© 2010 Jones and Bartlett PublishersKey Characteristics of the U.S. Health Care System
6
Characteristics Of The U.S. Health Care SystemNo 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.
7
8
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.
Characteristics Of The U.S. Health Care System
9
Technology-Driven and Focuses on Acute Care-Technology has had successful interventions, but is overused.-This prohibits Employers extending benefits to part-time workers andInsurers lowering
premiums.
Characteristics Of The U.S. Health Care System
0
High in 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.
Characteristics Of The U.S. Health Care System
1
Characteristics Of The U.S. Health Care System
High in Cost, Unequal in Access, and Average in Outcome
-
Access
The
ability of an individual to obtain health care services when
needed.
2
High in Cost, Unequal in Access, and Average in Outcome
-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.
Characteristics Of The U.S. Health Care System
3
High in 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
4
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
5
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
6
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
7
Imperfect Market Conditions
-A
free market requires that patients have
I
nformation
about the availability of various
services.
Characteristics Of The U.S. Health Care System
8
Imperfect Market Conditions
-In
a free market, patients as consumers must:
D
irectly
bear the cost of services received.
M
ake
decisions about the purchase of health care
services.
Characteristics Of The U.S. Health Care System
9
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
0
Market Justice and Social Justice:
Conflict Throughout Health Care
-Market
justice and social justice are:
T
wo
contrasting theories that govern the production and distribution of health care services in the United States.
Characteristics Of The U.S. Health Care System
1
Multiple Players and Balance of Power
The
key system players have been:
P
hysicians
A
dministrators
of health care institutions
I
nsurance
companies
L
arge
employers
G
overnment
Characteristics Of The U.S. Health Care System
2
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
-
E
thically
providing quality health care in an efficient
manner.
-S
afeguarding
one’s own health and using resources
sensibly.
Characteristics Of The U.S. Health Care System
3
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
4
5
National Health InsuranceCanada 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
6
National Health SystemsGreat Britain uses this system.-Finance a tax-supported national health insurance program: Government manages the infrastructure for the delivery of medical care.
M
ost
medical institutions are operated by
government.
M
ost
providers are government
employees.
Health Care Systems Of Other Developed Countries
7
Socialized Health Insurance Systems
Germany uses this style
-Health
care is financed through government-mandated contributions by employers and
employees.
-Health
care
is 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
8
Systems FrameworkSystems consist of: -A set of interrelated and interdependent components designed to achieve some common goals.
9
Systems FrameworkThe systems framework:-Explains the structure of health care services in the U.S. based on the foundations.-Provides a logical arrangement of various components.
-D
emonstrates
a progression from inputs to
outputs.
0
The framework outlines:
-System
Foundations
-System
Resources
-System
Processes
-System
Outcomes
-System
Outlook
Look at Figure 1.2, page 25
Systems Framework
1
2
Conclusion
The U.S. has a unique system of delivery, therefore
C
ontinuous
and comprehensive care is not enjoyed by all
Americans.
I
t’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.

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