Chapter 1 Powerpoint .pptx

8/18/2019 Chapter 1 Powerpoint .pptx

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Chapter 1

An Overview of US Health

Care Delivery


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Class Objectives• At the end of the class, you should:

– Understand the basic nature of the U Shealth care syste!

–

"e able to outline the four #ey functionalco!ponents of the health care deliverysyste!

– Discuss the pri!ary characteristics of the

U S health care syste! – Have an overview of health care syste!s in

selected countries – Understand the syste!s !odel as applied

to health care delivery


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orHealth Services DeliverySyste!• "roadly De%ned:

– !ajor co!ponents of the syste! andprocesses that enable people to receivehealth care

• &estricted de%nition: – the act of providin' health care to

patients (i e in a hospital or aphysician)s clinic*


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+ri!ary Objectivesof a Health Care Syste!1 $o enable all citi ens to receive

health care services- $o deliver services that are cost.

e/ective and !eet establishedstandards of 0uality


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$he U S Health Care Syste!

• t)s Uni0ue – it)s not a syste! – no universal health care %nanced by

ta2es – no entitle!ent – no other country operates li#e the U S – critical issues related to cost, access and

0uality


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• $he health care wor#force e!ploys over13 4 !illion people

• 565,777 active 8Ds• 97,457 DO)s• - 3 !illion nurses• ,9; hospitals• 1 ,977 nursin' ho!es• 1,1-5 health centers• 677< !edical, dental and phar!acy schools• 1, 77< nursin' pro'ra!s


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$he U S Health CareSyste!• 8ore nu!bers:

– 1;4 !illion A!ericans with privateinsurance

– 46 4 !illion 8edicare bene%ciaries – 49 5 !illion 8edicaid recipients – 7 9 !illion (13 9=* uninsured


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>inancin' and nsurance8echanis!s• ?!ployer.based health insurance

– (private*• +rivately.purchased health insurance

– (private*• @overn!ent pro'ra!s (public*

– State ?!ployees @roup• e!ployees

– 8edicare• elderly and certain disabled people

– 8edicaid and CH +• indi'ent, poor (if they !eet the eli'ibility criteria*,

children


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• $here)s little or no: – networ#in' –

interrelated co!ponents – standardi ation – coordination –

cost contain!ent as a whole – plannin', direction


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• Has: – duplication – overlap – inade0uacy – inconsistency – waste – co!ple2ity – ine ciency – %nancial !anipulation – fra'!entation


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• Beads the world in: – !edical technolo'y –

!edical trainin' – research – sophisticated

•

institutions• products• processes


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Characteristics Ofthe U S Health Care Syste!• +olitical cli!ate• ?cono!ic develop!ent•

$echnolo'ical pro'ress• Social and cultural values• +hysical environ!ent•

+opulation characteristics(de!o'raphics, health trends*• @lobal in uences (see %'ure 1.-*


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$en Characteristics thatDi/erentiate

the U S Health Care Syste!1 o central a'ency 'overns a syste!- Access is selective based on insurance6 Health care o/ered under i!perfect !ar#et activity4 $hird party insurers are inter!ediaries between

%nance and delivery8ultiple payers are cu!berso!e

3 "alance of power, no do!ination9 Be'al ris# a/ects practice behavior5 ew technolo'y creates de!and for its use; ew service settin's alon' a continuu!17 Euality is achievable


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the U S Health Care Syste!1* o Central A'ency – 8ost developed nations have a national health care

pro'ra! where every citi en is entitled to receive aset of service

– $o control costs, use 'lobal bud'et to deter!ine totalhealth care e2penses

– @overn!ent usually controls fre0uency of healthcare services, especially e2pensive !edical

technolo'y use – $he U S has !ostly private %nancin' and delivery – +rivate %nancin' throu'h e!ployers at = and

'overn!ent at 4 =


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$en Characteristics that Di/erentiatethe U S Health Care Syste!

1* o Central A'ency – +rivate health care, hospitals, physicians are

independent of 'overn!ent – o one !onitors total e2penses throu'h 'lobal

bud'ets and utili ation – U S does deter!ine public.sector e2penses and

rei!burse!ent rates for 8edicare and 8edicaid – @overn!ent sets standards of participation

throu'h policy and re'ulations – providers !ust co!ply with standards to be

certi%ed to provide 8edicaid F 8edicare

patients

$


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-* +artial access – Universal access: Health care is available

to all citi ens –

Access: the ability to obtain health carewhen needed – n U S , access restricted to those who:

a* have health insurance throu'h an

e!ployerb* are covered under a 'overn!enthealth care plan

c* can a/ord to buy insurance out of

poc#et


the U S Health Care Syste!

$ h h


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-* +artial access – $hose unable to pay wait until a health proble!

arises then receive health care at the

e!er'ency roo!• hospital does not receive pay!ent• a for! of catastrophic health care insuranceG

– +ri!ary Care: basic and routine care –

Bac# of access to pri! care a bi' reason forU S ) la' in population health (i e infant!ortality, life e2pectancy*



$ Ch i i h


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6* !perfect 8ar#et – n national health care, econo!ic

!ar#ets do not e2ist – +rivate health care consolidatin',

for!in' alliances and inte'ratin'delivery syste!

• networ#s of health care or'ani ations



$ Ch i i h


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6* !perfect 8ar#et (cont)d* – U S has a 0uasi.!ar#et where health care ispartially !ana'ed by free !ar#ets

•

patients (buyers* and providers (sellers* act independently• prices set by interaction of supply and de!and• unrestrained co!petition on basis of price and 0uality• patients !ust have info of availability of di/erent services(technolo'y too co!plicated, s#ills too advanced*

•

patients have info on price and 0uality on each provider• patients !ust bear cost of services received• patients !a#e decisions about the purchase of health careservices




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$en Characteristics that Di/erentiatethe U S Health Care Syste!

6* !perfect 8ar#et (cont)d* – U S has a 0uasi.!ar#et where healthcare is partially !ana'ed by free!ar#ets

• patients have info on price and 0uality oneach provider

• patients !ust bear cost of services received• patients !a#e decisions about the purchaseof health care services

$ Ch i i h


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6* !perfect 8ar#et (cont)d* – te! pricin'

• obtain fees char'ed for service (sur'eon)s

price*• services can)t be deter!ined prior to procedure – +ac#a'e pricin'

• bundled fee for a 'roup of related services –

Capitation• all health care services include one set fee per

person, !ore all.enco!passin'



$ Ch i i h


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• +hanto! providers – bill for services separately

• anesthesiolo'y, patholo'ist, supplies, hospital

facility use• Supplier provider.induced de!and

– +hysicians have in uence on creatin'de!and for their %nancial bene%t

– +hysicians receive care beyond what isnecessary

• (i e follow.up visits, tests, unnecessary sur'ery*



$ Ch i i h


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4* $hird.+arty nsurers and +ayers – +atient is %rst party – +rovider is second party – nter!ediary is third party

• a wall of separation between %nancin'and delivery

• 0uality of care is a secondary concern



$ Ch t i ti th t


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* 8ultiple +ayers – $he U S has !any payers,

co!pany can choose di/erentplans

• a billin' and collection ni'ht!are• syste! beco!es !ore cu!berso!e

–

Sin'le.payer syste!• a national health care syste! that isusually the pri!ary payer.'overn!ent



$ Ch t i ti th t


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3* +ower "alancin' – 8ultiple +layers

• +hysicians, ad!inistration, insurance,'overn!ent, e!ployers

– >ra'!ented self.interests• prevents an entity fro! do!inatin'




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9* Be'al &is#s – $he U S is a liti'ious society – +ractioners en'a'e in defensive !edicine

• prescribe dia'nostic tests, return chec#ups,

docu!entation5* Hi'h $echnolo'y

– $he U S , a hotbed of research and innovations• Creates de!and for new services despite hi'h

costs• Iith capital invest!ents, !ust have utili ation• Be'al ris#s for providers denyin' new technolo'y

Di/erentiate


$ Ch t i ti th t


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;* Continuu! of Services – 8edical services has three broad

cate'ories:•

curative• restorative• preventative

– Health care is not con%ned to the

hospital (See table 1.-*17* Euest for Euality – Continuous Euality !prove!ent – Hi'her e2pectations – Euality standards with co!pliance




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@overn!ent)s &oles in the U SHealth Service Syste!• 8ajor %nancier of health care

delivery• Deter!ine rei!burse!ent rates to

providers who render 8edicare 8edicaid services

• &e'ulates throu'h licensin'personnel and health careestablish!ents

• Health policy


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$he "lended +ublic and +rivateU S Health Care Syste!• $he results:

– !ulti %nancial arran'e!ents – !any insurance co!pany with di/erent

ris# !echanis!s – !any payers with di/erent deter!inates – !any consultin' %r!s o/erin':

• plannin',• cost contain!ent,• 0uality,• !ini!i in' resources


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$he Euad.>unction 8odel

• >unctional co!ponents of healthcare delivery :1* >inancin'

• to buy insurance or to pay for health careservices consu!ed usually e!ployer.based

-* nsurance•

to protect a'ainst catastrophic ris#• deter!ine the pac#a'e the individual is

eli'ible to receive


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$he Euad.>unction 8odel• >unctional co!ponents of health care delivery :

6* delivery• +rovider: any entity that delivers health care

services and receives insurance pay!entdirectly for those services

4* pay!ent• &ei!burse!ent: the deter!ination of how

!uch to pay for a service•

>unds co!e fro! pre!iu!s paid toinsurance co!pany• +atient usually pays co.pay, and the

insurance co!pany pays re!ainder• $here)s so!e overlap dependent on private,


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8ajor +layers in the U S HealthService Syste!• Iho does these functionsG

– +hysicians – Ad!inistrators –

nsurance e2ecutives – Bar'e e!ployers – @overn!ent – See %'ure 1.1


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A Disenfranchised Se'!ent

• n the U S , insurance is e!ployer.based – the une!ployed usually have no insurance

• ?ven if e!ployed, e!ployees do not haveinsurance because:1* ?!ployers not !andated to o/er insurance

• pre!iu! cost sharin' – rarely paid at 177= if at all – bene%t: 'roup rate or availability of insurance

-* +articipation in health insurance is voluntary


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ational and Social nsuranceand Syste!s• ational Health nsurance ( H *

– @overn!ent %nances health care throu'hta2es

– Care provided by private providers• ational Health Syste!

– >inancin' a ta2 supported H – @overn!ent !ana'es the infrastructure for

delivery – @overn!ent operates !edical institutions• +roviders are 'overn!ent e!ployees or

or'ani ed


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ational and Social nsuranceand Syste!s• Sociali ed Health nsurance

– >inanced throu'h 'overn!ent.!andated contributions by

e!ployers and e!ployees – Health delivered by private providers – nsurance and pay!ent closely

inte'rated – @overn!ent e2ercises overall control


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Cost Control inational Health Care +ro'ra!s

• @lobal bud'ets – deter!ine the national health care

e2penditures• Health care resources are allocated

in the bud'etary: – availability and disse!ination of service

and technolo'y – rei!burse!ent levels


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ational Health Care +ro'ra!s

• $heoretically, no one is uninsured• Universal access:

– is !ana'ed by the 'overn!ent – provides a de%ned set of health care

services to all citi ens


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ational Health nsurance ( H *

• @overn!ent %nances health care throu'h ta2es,but rendered by private providers

• ational health care pro'ra! (i e , Canada*&e0uires 'overn!ent consolidation of %nancial,insurance and pay!ent

• @overn!ent !ana'es the infrastructure – !edical institutions are operated by 'overn!ent – wor#ers are 'overn!ent wor#ers or or'ani ed

(i e physicians, nursesJ*• $a2.supported• @reat "ritain


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Sociali ed Health nsurance

• @er!any, srael, and Kapan:• >inanced throu'h 'overn!ent.

!andated contributions bye!ployers and e!ployees

• Health care delivered by privateproviders

• >inanced throu'h 'overn!ent.!andated contributions bye!ployers and e!ployees

• Health care delivered by private


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Sociali ed Health nsurance

• +rivate, not.for.pro%t insurance co!panies – called sic#ness funds – collect and pay physicians and hospitals

•

nsurance and pay!ent are closelyinte'rated• >inancin' inte'rated with insurance and

pay!ent•

@overn!ent has overall control – See $able 1.6


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!plications for Health Services8ana'ers• Understand chan'es shifts in the

syste!• $a#e advanta'e of new !ar#et

opportunities and !ini!i e threats• ?valuate need for trainin'• Understand the i!pact of new

re'ulations


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!plications for HealthServices 8ana'ers• +osition the or'ani ation

– #now where you %t in the !acroenviron!ent

•

Handle $hreats F Opportunities – be proactive with chan'es in

rei!burse!ent, insurance, delivery• ?valuate !plications

– Boo# at policy chan'es


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Syste!s >ra!ewor#

• See >i'ure 1.4 – Syste! >oundations – Syste! &esources – Syste! +rocesses – Syste! Outco!es – Syste! Outloo#


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ACA $a#eaway

• @oal: increase access to health care and !a#eit !ore a/ordable

• All US citi ens and le'al residents are re0uired

to have health insurance or pay a %ne• Avenues for coverin' the uninsured: 8edicaide2pansion and 'overn!ent.run e2chan'es

• nsurance co!panies are re0uired to include

covera'e for a variety of health care Services

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