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Health Care USA Chapter One

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Be able to outline four components of the health care delivery system. ... Change and Reform'Health Policy'(Chapter 13) The System Framework. FUTURE TRENDS ... – PowerPoint PPT presentation

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Title: Health Care USA Chapter One


1
Health Care USAChapter One
  • At the end of the class, you should
  • Understand the basics of the U.S. health care
    system.
  • Be able to outline four components of the health
    care delivery system.
  • Be able to differentiate the U.S. health care
    system and the free market.
  • Have an overview of health care in other
    countries.

2
Health Care USA
  • There are two key objectives of a health care
    delivery system
  • To provide universal access and to deliver
    services that are cost-effective.
  • To meet pre-established standards of quality.

3
In the United States
  • Health care.
  • Is not delivered through a standard linear
    system, but instead through a kaleidoscope of
    financing, insurance, delivery, and payment
  • mechanisms that are not standardized and are
    coordinately loosely.

4
Health Care Delivery
  • There are four functional components
  • Financing
  • to purchase insurance or to pay for health care
    services consumed
  • Insurance
  • to protect against catastrophic risk

5
Health Care Delivery
  • four functional components
  • Delivery
  • To provide health care services.
  • Payment
  • To reimburse providers for services rendered.

6
Healthcare Delivery
  • Access to health care is determined by four main
    factors
  • Ability to pay
  • Availability of service
  • Payment
  • Barriers to enablement

7
Healthcare-Financing
  • Financing and insurance mechanisms are divided
    into
  • Private (employer-based or privately purchased
    health insurance).
  • Public (Medicare and Medicaid) sectors.

8
United States
  • Key elements that contribute to the number of
    uninsured persons.
  • Unemployment
  • Lack of a requirement for employers to provide
    insurance
  • Lack of a requirement for employees to purchase
    health insurance when it is offered
  • Lack of eligibility for government-funded
    programs.

9
Healthcare Delivery
  • The problem of rising health care costs was a
    major force driving the rise of
  • MANAGED CARE.

10
Healthcare Managed Care
  • Managed care is a system of health care
    delivery.
  • That seeks to achieve efficiencies by integrating
    the basic functions of health care delivery
  • Employs mechanisms to control utilization of
    medical services
  • Fees for services rendered.

11
United States Healthcare
  • All major developed countries except for the
    United States offer national health care
    programs.
  • These programs provide universal access through
    health care delivery systems
  • that are managed by the respective governments
    and provide a defined set of health care services
    to all citizens.

12
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
  • (HIV, black lung, homeless, migrant workers)
  • 300 medical, dental and pharmacy schools
  • 1,500 nursing programs

13
Healthcare Delivery
  • More numbers
  • 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

14
National Health Systems
  • There are three models
  • National health insurance (NHI)
  • a tax-supported
  • national program in which services are rendered
    by
  • private providers but paid for by the government.

15
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.

16
National Health Systems
  • Socialized health insurance (SHI)
  • a program in which health care is financed by
  • government-mandated contributions by employers
    and employees, and in which health care is
    delivered by private providers.

17
Healthcare Delivery
  • Uniqueness of the U.S. health care delivery
    system
  • Lack of a central agency
  • Lack of universal access
  • An imperfect market.
  • The presence of third-party insurers and multiple
    payers.

18
Healthcare Delivery
  • Imperfect Market
  • Item pricing
  • obtain fees charged for service
  • (surgeons price)
  • services cant 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 all-encompassing

19
Healthcare DeliveryImperfect Market contd
  • Phantom providers
  • bill for services separately
  • anesthesiology, pathologist, supplies, hospital
    facility use
  • Supplier/provider-induced demand
  • Physicians have influence on creating demand for
    their financial benefit
  • Physicians receive care beyond what is necessary
  • (i.e. follow-up visits, tests, unnecessary
    surgery)

20
Healthcare Delivery
  • Third-Party 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

21
Healthcare Delivery
  • The practice of defensive medicine.
  • The practice of ordering medical tests,
    procedures, or consultations of doubtful clinical
    value in order to protect the prescribing
    physician from malpractice suits.  

22
Healthcare Delivery
  • An understanding of the health care delivery
    system is essential
  • Effective management of health services.
  • Help managers understand the shifts occurring in
  • the system
  • Enable senior managers to take advantage of
  • opportunities and minimize threats evaluate the
  • need for training, and understand the impact of
  • new regulations.

23
Healthcare Delivery
  • Has
  • duplication
  • overlap
  • inadequacy
  • inconsistency
  • waste
  • complexity
  • inefficiency
  • financial manipulation
  • fragmentation

24
Healthcare Delivery
  • The system is comprised of a set of interrelated
    and interdependent components designed to achieve
    common goals.
  • The systems framework provides an organized
    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.

25
The System Framework
  • E N V I R O N M E N T
  • 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)

26
The System FrameworkSystem Features
  • II. SYSTEM RESOURCES
  • Human Resources
  • Health Services Professionals(Chapter 4)
  • Nonhuman Resources
  • MedicalTechnology (Chapter 5)
  • HealthServices Financing (Chapter 6)

27
The System Framework System Features
  • III. SYSTEM PROCESSES
  • The Continuum of CareOutpatient and Primary Care
    Services(Chapter 7)
  • Inpatient Facilities and Services(Chapter 8)
  • Managed Care and Integrated Organizations(Chapte
    r 9)
  • Special PopulationsLong-Term Care(Chapter 10)
  • Health Services for Special Populations(Chapter
    11)

28
The System Framework System Features
  • IV. SYSTEM OUTCOMES
  • Issues and ConcernsCost, Access, and
    Quality(Chapter 12)
  • Change and ReformHealth Policy(Chapter 13)

29
The System Framework
  • FUTURE TRENDS
  • V. SYSTEM OUTLOOK
  • The Future of Health Services Delivery (Chapter
    14)

30
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
    ensuring access.

31
Terminology
  • Administrative costs-Costs that are incidental
    for the delivery of health delivery services.
    Those costs are associated with
  • Billing/collection of claims for delivered
    services.
  • Time incurred by employers for selection of
    insurance carriers.
  • Costs incurred by insurance and managed care
    organizations for marketing their products and
    cost negotiation for rates.

32
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 persons 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 individual
    covered under the plan.

33
Terminology
  • Health plan (or plan, for short). The
    contractual arrangement between the MCO and the
    enrolleeincluding the collective array of
    covered health services that the enrollee is
    entitled tois referred to as the health plan.
    It uses selected providers from whom the
    enrollees can choose to receive routine services.
    This primary care provideroften a physician in
    general practiceis 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.

34
Terminology
  • Continuum of Services - Medical care services are
    generally classified into three broad categories
  • Curative (e.g., drugs, treatments, and
    surgeries).
  • Restorative (e.g., physical, occupational, and
    speech therapies)
  • Preventive (e.g., prenatal care, mammograms, and
    immunizations).

35
Terminology Continuum of Services
  • Health care service settings
  • No longer confined to the hospital and the
    physicians office, where many of the
    aforementioned services were once delivered.
  • Several new settings, such as home health,
    subacute care units, and outpatient surgery
    centers have emerged in response to the changing
    configuration of economic incentives.
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