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Unformatted text preview: Health Care USA Health Care USA Chapter One At the end of the class, you should:
Understand the basics of the U.S. health care system. system. Be able to outline four components of the health care Be delivery system. delivery Be able to differentiate the U.S. health care system Be and the free market. and Have an overview of health care in other countries. Health Care USA Health Care USA
There are two key objectives of a health care delivery system: To provide universal access and to deliver services that are costeffective. To meet preestablished standards of quality. In the United States In the United States
Health care…. Is not delivered through a standard linear Is system, but instead through a kaleidoscope of financing, insurance, delivery, and payment financing, mechanisms that are not standardized and are mechanisms coordinately loosely. coordinately Health Care Delivery Health Care Delivery There are four functional components… Financing to purchase insurance or to pay for health care services consumed services Insurance to protect against catastrophic risk Health Care Delivery Health Care Delivery four functional components… Delivery To provide health care services. To Payment To reimburse providers for services rendered. Healthcare Delivery Healthcare Delivery Access to health care is determined by four Access main factors: main Ability to pay Ability Availability of service Availability Payment Payment Barriers to enablement Barriers Healthcare-Financing Financing and insurance mechanisms are Financing divided into… divided Private (employer-based or privately purchased Private health insurance). health Public (Medicare and Medicaid) sectors. United States Key elements that contribute to the number of Key uninsured persons…. uninsured Unemployment Lack of a requirement for employers to provide Lack insurance insurance Lack of a requirement for employees to purchase Lack health insurance when it is offered health Lack of eligibility for government-funded Lack programs. programs. Healthcare Delivery Healthcare Delivery The problem of rising health care costs was a The major force driving the rise of… major MANAGED CARE. MANAGED Healthcare – Managed Care Healthcare – Managed Care Managed care is a system of health care Managed delivery…. That seeks to achieve efficiencies by integrating That the basic functions of health care delivery the Employs mechanisms to control utilization of Employs medical services Fees for services rendered. United States Healthcare United States Healthcare All major developed countries except for the All United States offer national health care programs. programs. These programs provide universal access These through health care delivery systems through that are managed by the respective governments and provide a defined set of health care services to all citizens. The Health Care Workforce
Employs approximately 10 million people
850,000 doctors 3 million nurses 168,000 dentists 208,000 pharmacists 700,000 administrators 300,000 physical therapy, occupational therapy, speech 5,810 hospitals 17,000 nursing homes 5,720 mental health hospitals 11,700 home health and hospice agencies 800 primary care programs 300 medical, dental and pharmacy schools (HIV, black lung, homeless, migrant workers…) Healthcare Delivery Healthcare Delivery
– 190 million Americans with private ins – 39.6 million Medicare beneficiaries – 41.4 million Medicaid recipients – 1,000 insurance companies – 42 BlueCrossBlueShield plans – 540 health maintenance organizations – 925 preferred provider organizations National Health Systems National Health Systems
There are three models: National health insurance (NHI): a tax-supported tax-supported national program in which services are rendered by private providers but paid for by the government. government. National Health Systems National Health Systems National health system (NHS) a tax-supported national program in which the government finances and also controls the
health care service infrastructure. health National Health Systems National Health Systems Socialized health insurance (SHI): a program in which health care is financed by government-mandated contributions by government-mandated employers and employees, and in which health care is delivered by private providers. providers. Healthcare Delivery Healthcare Delivery
Uniqueness of the U.S. health care delivery Uniqueness system… system… Lack of a central agency Lack of universal access An imperfect market. The presence of third-party insurers and The multiple payers. Healthcare Delivery Healthcare
Imperfect Market … Item pricing obtain fees charged for service (surgeon’s price) services can’t be determined prior to procedure Package pricing bundled fee for a group of related services Capitation all health care services include one set fee per person, more allencompassing Healthcare Delivery Healthcare Imperfect Market cont’d… Phantom providers bill for services separately anesthesiology, pathologist, supplies, hospital facility use Supplier/providerinduced demand Physicians have influence on creating demand for their financial benefit Physicians receive care beyond what is necessary (i.e. followup visits, tests, unnecessary surgery) Healthcare Delivery Healthcare Delivery
ThirdParty Insurers and Payers – Patient is first party – Provider is second party – Intermediary is third party • a wall of separation between financing and delivery – quality of care is a secondary concern Healthcare Delivery Healthcare The practice of defensive medicine.* *The practice of ordering medical tests, procedures, *The or consultations of doubtful clinical value in order to protect the prescribing physician from malpractice suits. malpractice Healthcare Delivery Healthcare Delivery An understanding of the health care delivery An system is essential… system Effective management of health services. Help managers understand the shifts occurring in the system Enable senior managers to take advantage of Enable opportunities and minimize threats evaluate the need for training, and understand the impact of Healthcare Delivery Healthcare Delivery
– – – – – – – – – duplication overlap inadequacy inconsistency waste complexity inefficiency financial manipulation fragmentation Healthcare Delivery Healthcare Delivery The system is comprised of a set of interrelated and The interdependent components designed to achieve common goals. The systems framework provides an organized The approach to understanding the various components of the U.S. health care delivery system and it is comprised of five key components; system foundations, system resources, system processes, system outcomes, and system outlook. system The System Framework The
ENVIRONMENT I. SYSTEM FOUNDATIONS Cultural Beliefs and Values, and Historical Developments
“Beliefs, Values, and Health” (Chapter 2) “The Evolution of Health Services in the United States” (Chapter 3) The System Framework The System Features
II. SYSTEM RESOURCES Human Resources “Health Services Professionals”(Chapter 4) Nonhuman Resources “MedicalTechnology” (Chapter 5) “HealthServices Financing” (Chapter 6) The System Framework The System Features III. SYSTEM PROCESSES The Continuum of Care“Outpatient and Primary The Care Services”(Chapter 7) Care “Inpatient Facilities and Services”(Chapter 8) “Managed Care and Integrated Managed Organizations“(Chapter 9) Organizations“(Chapter Special Populations“Long-Term Care”(Chapter Special 10) 10) “Health Services for Special Populations”(Chapter Health 11) 11) The System Framework The System Features IV. SYSTEM OUTCOMES Issues and Concerns“Cost, Access, and Issues Quality”(Chapter 12) Quality”(Chapter Change and Reform“Health Policy”(Chapter 13) The System Framework The
FUTURE TRENDS V. SYSTEM OUTLOOK “The Future of Health Services Delivery” (Chapter The 14) 14) Terminology Terminology Access - The ability of an individual to obtain health care services when needed. In the United States, access is restricted to (1) those who have health insurance through their employers, (2) those covered under a government health care program, (3) those who can afford to buy insurance out of their own private funds, and (4) those who are able to pay for services privately. Health insurance is the primary means for ensur-ing access. Terminology Terminology Administrative costs-Costs that are incidental -Costs for the delivery of health delivery services. Those costs are associated with Those Billing/collection of claims for delivered services. Time incurred by employers for selection of Time insurance carriers. insurance Costs incurred by insurance and managed care Costs organizations for marketing their products and cost negotiation for rates. negotiation Terminology Terminology Balance bill- the billing of leftover sum by the provider to the patient after the insurance has only partially paid the charges initially billed. Capitation- A set amount (or a flat rate) to cover a person’s medical care for a specified period, usually monthly. Defensive medicine demand- Excessive medical tests and procedures performed as a protection against malpractice lawsuits, otherwise regarded as unnecessary. Enrollee- (member) refers to the in-dividual covered under the plan. Terminology Terminology Health plan (or “plan,” for short). The contrac-tual arrangement between the MCO and the enrollee—including the collective array of covered health services that the enrollee is entitled to—is referred to as the health plan. It uses selected providers from whom the enrollees can choose to receive routine services. This primary care provider—often a physician in general practice—is customarily charged with the responsibility to determine the appropriateness of higher level or specialty services. The primary care provider refers the patient to receive specialty services if deemed appropriate. Terminology Terminology
Continuum of Services - Medical care services Continuum are generally classified into three broad categories: Cura-tive (e.g., drugs, treatments, and surgeries). Cura-tive Restorative (e.g., physical, occupational, and Restorative speech therapies) speech Preventive (e.g., prenatal care, mammograms, and Preventive immu-nizations). Terminology Terminology “Continuum of Services”
Health care service settings: No longer confined to the hospital and the physician’s No office, where many of the aforementioned services were once deliv-ered. Several new settings, such as home health, subacute Several care units, and outpatient surgery centers have emerged in response to the changing configuration of economic incentives. ...
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This note was uploaded on 03/06/2011 for the course HE 319 taught by Professor Herry during the Spring '11 term at Lindsey Wilson.
- Spring '11