Health Care Delivery in the United States

Chapter 13

Introduction

• Health care delivery in U.S. is unlike other developed countries• Is delivered by an array of providers in a

variety of settings

• Is paid for in a variety of ways

• Is U.S. health care a “system?”

History of Health Care Delivery in the U.S.

• Self-care has been a category of health care throughout history and today• Assumed self-care occurs before seeking

professional help

• From colonial times through late 1800’s, anyone trained or untrained could practice medicine

• Past medical education not as rigorous as today

History of Health Care Delivery in the U.S.

• Early medical education not grounded in science; experience-based only, prior to 1870

• Most care was provided in patients’ homes

• Hospitals only in large cities and seaports• Functioned more in a social welfare manner

• Not clean; unhygienic practice

• Almshouses

• Pesthouses

Health Care Delivery in the Late 1800’s – Early 1900’s

• Care moved from patient’s home to physician’s office and hospital• Building and staffing better; designed for

patient care; trained people; medical supplies

• Reduced travel time

• Science had bigger role in medical education

• Mortality decline due to improved public health measures

• Early 1920s chronic diseases passed communicable as leading causes of death

• New procedures: X-ray, specialized surgery, chemotherapy, ECG

• Training: doctors and nurses more specialized

• 1929 – 3.9% GDP on health care

• Two party system – patients and physicians• Physicians collected own bills, set and adjusted

prices based on ability to pay

Health Care Delivery in the Late 1800’s – Early 1900’s

Health Care Delivery – 1940s and 1950s

• WWII impact• Due to wage restrictions employers used health

insurance to lure workers

• Huge technical strides in 1940s and 1950s

• Hill-Burton Act

• Improved procedures, equipment, facilities meant rise in cost of health care

• Concept of health care as basic right vs. privilege

Health Care Delivery – 1960s

• Late 1950s had overall shortage of quality care and maldistribution of health care services

• Increased interest in health insurance

• Third-party payment system became standard method of payment

• Cost of health care rose

• Increased access, little expense for those with insurance; those without unable to afford care

• 1965 Medicare and Medicaid

Health Care Delivery – 1970s

• Health Maintenance Organization Act of 1973

• National Health Planning and Resources Development Act of 1974• Health Systems Agencies in place to cut costs

and prevent building unnecessary facilities and purchasing unnecessary equipment

Health Care Delivery – 1980s

• Reagan and Congress eliminated Health System Agencies

• Deregulation of health care delivery

• Proliferation of new medical technology

• Questions in medical ethics

• Elaborate health insurance programs

Health Care Delivery – 1990s

• American Health Security Act of 1993

• Managed care• Achieve efficiency

• Control utilization

• Determine prices and payment

• 1996 – U.S. health care bill $1 trillion; 13.6% GDP

• CHIP

Health Care Delivery in the 21st Century

• 2010 – U.S. health care costs $2.6 trillion; 17.3% GDP• Health care costs outpacing inflation for past

few decades• America spends more per capita annually on

health care than any other nation

• Still no national Patient Bill of Rights

• Health Savings Accounts

• 2010 – Affordable Care Act

Health Care Structure

• Spectrum of health care delivery• Various types of care

• Types of health care providers

• Health care facilities and their accreditation

Spectrum of Health Care Delivery

• Population-based public health practice

• Medical practice

• Long-term practice

• End-of-life practice

Population-Based Practice

• Interventions aimed at disease prevention and health promotion

• Health education• Empowerment and motivation

• Much takes place in governmental health agencies• Also occurs in a variety of other settings

Medical Practice

• Primary medical care• Clinical preventive services; first-contact

treatment; ongoing care for common conditions

• Secondary medical care• Specialize attention and ongoing management

• Tertiary medical care• Highly specialized and technologically

sophisticated medical and surgical care

• For unusual and complex conditions

Long-Term Practice

• Restorative care• Provided after surgery or other treatment• Rehab care, therapy, home care

• Inpatient and outpatient units, nursing homes, other settings

• Long-term care• Help with chronic illnesses and disabilities

• Time-intensive skilled care to basic daily tasks

• Nursing homes and various settings

End-of-Life Practice

• Services provided shortly before death

• Hospice care• Terminal diagnosis

• Variety of settings

Spectrum of Health Care Delivery

Types of Health Care Providers

• 14.5 million workers in U.S. (10.4% of pop.)• 41.3% in hospitals; 25.6% in ambulatory care

settings; 16.3% in nursing/residential facilities

• Over 200 types of careers in industry• Independent providers

• Limited care providers

• Nurses

• Nonphysician practitioners

• Allied health care professionals

• Public health professionals

Independent Providers

• Specialized education and legal authority to treat any health problem or disease

• Allopathic and osteopathic providers

• Nonallopathic providers

Allopathic and Osteopathic Providers

• Allopathic providers• Produce effects different from those of diseases

• Doctors of Medicine (MDs)

• Osteopathic providers• Relationship between body structure & function

• Doctors of Osteopathic Medicine (DOs)

• Similar education and training

• Most DOs work in primary care

Nonallopathic Providers

• Nontraditional means of health care

• Complementary and Alternative medicine (CAM)• Used together with conventional medicine,

therapy is considered “complementary”; in place of considered “alternative”

• Chiropractors, acupuncturists, naturopaths, etc.

• Natural products, mind-body medicine, manipulation, etc.

Limited (or Restricted) Care Providers

• Advanced training in a health care specialty

• Provide care for a specific part of the body

• Dentists, optometrists, podiatrists, audiologists, psychologists, etc.

Nurses

• Over 4 million working in nursing profession

• Licensed Practical Nurses (LPNs)

• 1-2 years of education in vocational program

• Pass licensure exam

• Registered Nurses (RNs)

• Completed accredited academic program

• State licensure exam

• Advanced Practice Nurses (APNs)• Master or Doctoral degrees

Nonphysician Practitioners

• Practice in many areas similar to physicians, but do not have MD or DO degrees

• Training beyond RN, less than physician

• Nurse practitioners, certified midwives, physician assistants

Allied Health Care Professionals

• Assist, facilitate, and complement work of physicians and other health care specialists

• Categories• Laboratory technologist/technicians

• Therapeutic science practitioners

• Behavioral scientists

• Support services

• Education and training varies

Public Health Professionals

• Work in public health organizations

• Usually financed by tax dollars

• Available to everyone; primarily serve economically disadvantaged

• Public health physicians, environmental health workers, epidemiologists, health educators, public health nurses, research scientists, clinic workers, biostatisticians, etc.

Health Care Facilities & Their Accreditation

• Physical settings where health care is provided

• Inpatient care facilities• Patient stays overnight

• Outpatient care facilities• Patient receives care and does not stay

overnight

Inpatient Care Facilities

• Hospitals, nursing homes, assisted-living

• Hospitals often categorized by ownership• Private – profit making; specialty hospitals

• Public – supported and managed by government jurisdictions

• Voluntary – not-for-profits; ½ of U.S. hospitals

• Teaching and nonteaching hospitals

• Full-service or limited-service hospitals

Clinics

• Two or more physicians practicing as a group

• Do not have inpatient beds

• For-profit and not-for-profit

• Tax funded• Public health clinics, community health centers

• Over 1,100 community health centers in U.S.

• Support primary health care needs of underserved populations in the U.S.

Outpatient Care Facilities

• Care in a variety of settings, but no overnight stay regardless of why patient is in the facility• Health care practitioners’ offices, clinics,

primary care centers, ambulatory surgery centers, urgent care centers, services offered in retail stores, dialysis centers, imaging centers

Rehabilitation Centers

• Work to restore function

• May be part of a clinic or hospital, or freestanding facilities

• May be inpatient or outpatient

Long-Term Care Options

• Nursing homes, group homes, transitional care, day care, home health care

• Home health care• Growing due to restructuring of health care

system, technological advances, and cost containment

Accreditation of Health Care Facilities

• Assists in determining quality of health care facilities

• Process by which an agency or organization evaluates and recognizes an institution as meeting certain predetermined standards

• Joint Commission• Predominant accrediting organization

Health Care System Function

• U.S. “system” unique compared to other countries

• Recent decades’ challenges led to new legislation

• Affordable Care Act

• Goal: to put American consumers back in charge of their health coverage and care

• Signed into law March, 2010; changes to be implemented 2010-2020; some effective mid-2010; bulk go into effect 2014

Structure of the Health Care System

• U.S. structure – complex, expensive, many stakeholders, intertwined policies, politics

• Major issues:• Cost containment, access, quality• All equally important; expansion of one

compromises other two

Access to Health Care

Access to Health Care

• Variety of means to gain access• Insurance coverage and generosity of coverage

are major determinants of access to health care

• 2009 – 46.3 million uninsured (15.4%); 58.5 million uninsured for part of the year (19.4%)

• Likelihood of being uninsured greater for those: young, less education, low income, nonwhite

• Greatest reason for lack of insurance: cost

Access to Health Care

• 8 out of 10 uninsured are from working families

• Medically indigent

• Working poor

• Major component of Affordable Care Act is increasing the number of Americans with health insurance

Quality of Health Care

• Doing the right thing, at the right time, in the right way, for the right people, and having the best results

• Quality health care should be:• Effective

• Safe

• Timely

• Patient centered

• Equitable

• Efficient

The Cost of and Paying for Health Care

The Cost of and Paying for Health Care

• Reimbursement

• Fee-for-service

• Packaged pricing

• Resource-based relative value scale

• Prepaid health care

• Prospective reimbursement

Health Insurance

• A risk and cost-spreading process, like other insurance• Cost is shared by all in the group

• Generally “equitable,” but increased risk may lead to increased costs

Health Insurance Policy

• Policy

• Premiums

• Deductible

• Co-insurance

• Copayment

• Fixed indemnity

• Pre-existing condition• HIPPA

Types of Health Insurance Coverage

The Cost of Health Insurance

• Cost of insurance mirrors cost of care

• In U.S., burden falls primarily on the employer, then the employee• Increased worker share of premium

• Raising deductibles

• Increasing prescription co-payments

• Increasing number of exclusions

• Cost of policy determined by risk of group and amount of coverage provided

Self-Funded Insurance Programs

• Programs created for/by employers rather than using commercial insurance carriers

• Many benefits to the employer

• Generally for larger companies, unless low-risk employees

Health Insurance Provided by the Government

• Government health insurance plans only available to select groups

• Medicare

• Medicaid

• Children’s Health Insurance Program

• Veterans Administration benefits

• Indian Health Services

• Federal employees

• Health care for the uniformed services

• Prisoners

Medicare

• Covers more than 46.5 million people

• Federal health insurance program for those:• 65+, permanent kidney failure, certain disabilities

• SSA handles enrollment

• Contributory program through FICA tax

• Four parts• Hospital insurance (Part A), medical insurance

(Part B), managed care plans (Part C), prescription drug plans (Part D)

Medicare

• Part A – mandatory; has deductible & co-insurance

• Part B – those in part A automatically enrolled unless decline; has deductible & co-insurance

• Part C – offered by private insurance companies; not available in all parts of U.S.

• Part D – optional; run by insurance companies; monthly premiums; large number of plan available; complex to navigate

• Uses DRGs

Medicaid

• Health insurance program for low-income; no age requirement

• 46+ million covered by Medicaid

• Eligibility determined by each state; very costly budget item for states

• Noncontributory program

CHIP

• Created in 1997 for 10 years• Reauthorized in 2009 through 2013• Funding assisted by increase in federal excise

tax rate on tobacco

• 2009 – 7.8 million children enrolled

• Targets low-income children ineligible for Medicaid

• State/federal program

Problems with Medicare and Medicaid

• Programs created to help provide health care to those who might have impossibilities of obtaining health insurance

• Recurrent problems:• Some providers do not accept Medicare or

Medicaid as forms of payment

• Medicare/Medicaid fraud

Supplemental Health Insurance

• Help cover out-of-pocket costs not covered through primary insurance• Medigap

• Specific-disease insurance

• Fixed-indemnity

• Long-term care insurance• Preserve financial assets, prevent need for family

or friends to provide care, enable people to stay independent longer, easier to go into facility of choice

Who pays for long-term care?

Managed Care

• Goal to control costs by controlling health care utilization

• 2010 – 135 million enrolled in managed care plan

• Managed by MCOs

• Have agreements with providers to offer services at reduced cost

• Common features – provider panels, limited choice, gatekeeping, risk sharing, quality management and utilization review

Types of Managed Care

• Preferred provider organization (PPO)

• Exclusive provider organization (EPO)

• Health maintenance organization (HMO)• Staff model HMO

• Independent practice association (IPA)

• Other HMO models

Other Arrangements for Delivering Health Care

• National health insurance• A system in which the federal government

assumes responsibility for health care costs of entire population; primarily paid for with tax dollars

• U.S. only developed country without national health care plan

• Seven failed attempts at national health care in U.S. over past 70 years

• State health plans

Health Care Reform in the United States

• Consumer-directed health plans (CDHPs)• Consumer responsibility for health care

decisions with tax-sheltered accounts

• Health savings accounts

• High reimbursement arrangements

• Affordable Care Act

Discussion Questions

• How does payment for health care services affect the various types of health care providers now and in the future?

• What changes will need to occur for all U.S. citizens to have affordable health insurance?

• Is the Affordable Care Act going to effectively combat the numerous problems within the U.S. health care system?