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!
U.S. Health Care Delivery: A Systems Framework(Adapted from Shi & Singh, 2013) Structure & Processes Inputs Outputs Human Resources CostAccessQuality Underserved Populations Technology Managed Care & Health Networks Policy & Reform Financing Future Trends Historical Factors Cultural, Social, & Economic Factors System Foundations
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) 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 to private 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 is selectively 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