Transcript Health Systems

Chapter 13
Health Care Delivery
in the United States
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
• From colonial times through late 1800s,
anyone trained or untrained could practice
medicine
• Past medical education not as rigorous as
today
• Early medical education not grounded in
science; experience-based only, prior to 1870
History of Health Care Delivery in the
U.S.
• 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 1800s – Early 1900s
• 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
Health Care Delivery in the
Late 1800s – Early 1900s
• 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 – 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
• Deregulation of health care delivery
• Role of competition
• Competitive market approach of questionable
value in lowering health care costs
• Proliferation of new medical technology
• Elaborate health insurance programs
Health Care Delivery – 1990s
• American Health Security Act of 1993
• Managed care
• Achieve efficiency
• Control utilization
• Determine prices and payment
• Mid-1990s – percentage of GDP and dollars
spent on health care continued to increase
• CHIP
Health Care Delivery in the 21st
Century
• Medicare Prescription Drug, Improvement,
and Modernization Act of 2003
• The World Health Report 2000 – Health
Systems: Improving Performance
• U.S. ranked 37 out of 191 countries
• CHIP Reauthorization Act of 2009
• Affordable Care Act of 2010
Health Care System: Structure
• Spectrum of health care delivery
• Various types of care
• Types of health care providers
• Health care facilities in which health care is
delivered
Spectrum of Health Care Delivery
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Population-based public health practice
Medical practice
Long-term practice
End-of-life practice
Public Health Practice
• Interventions aimed at disease prevention and
health promotion, specific protection, and case
findings
• 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 services and settings
Types of Health Care Providers
• 13.4 million workers in U.S. (10.3% of pop.)
• 40.5% in hospitals; 25.4% in outpatient
settings; 16.6% 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
• Training and Education of Nurses
• Licensed Practical Nurses (LPNs)
• Registered Nurses (RNs)
• Professional nurses (those with a BSN degree)
• Advanced Practice Nurses (those with 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
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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 and 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
Outpatient Care Facilities
• One where a patient receives ambulatory care
• Variety of settings
• Health care practitioners’ offices, clinics,
primary care centers, ambulatory surgery
centers, urgent care centers, services offered in
retail stores, dialysis centers, imaging centers
• Group practices versus solo practices
• Clinics
Clinics
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Two or more physicians practicing as a group
Do not have inpatient beds
For-profit and not-for-profit
Some tax funded – created to meet needs of
medically indigent
Other Types of Outpatient Facilities
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Pharmacies
Urgent care centers
Ambulatory surgery centers
Non-hospital-based, specialty facilities
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
• Affordable Care Act 2010
• Extends coverage
• Curbs health insurance abuses
• Initiates improvements in quality of care
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
Cost Containment, Access, and Quality
Triangle
Access to Health Care
• Insurance coverage and generosity of coverage
are major determinants of access to health care
• 2011 – 46.3 million uninsured (15.1%); 58.7
million uninsured for part of the year (19.2%)
• Likelihood of being uninsured greater for
those: young, less education, low income,
nonwhite, male
• Greatest reason for lack of insurance: cost
followed by lost job or change in employment
Access to Health Care
• Lack of access to primary care
• Factors that limit access are lack of health
insurance, inadequate insurance, and poverty
• Major component of Affordable Care Act is
increasing the number of Americans with health
insurance
• Health insurance marketplaces – organizations
established to create more organized and
competitive markets for purchasing health
insurance
Quality of Health Care
• Quality health care should be:
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Effective
Safe
Timely
Patient centered
Equitable
Efficient
• Groups that measure quality: AHRQ, NCQA
The Cost of and Paying for Health
Care
• In 2014, projected health expenditures: $3.1
trillion
• U.S. biggest spender on health care in the
world by total spent
• Payments come from four sources:
• Direct or out-of-pocket payments
• Third-party payments from private insurance,
governmental insurance programs, and other
third-party payers
The Cost of and Paying for Health
Care
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Reimbursement
Fee-for-service
Packaged pricing
Resource-based relative value scale
Capitation
Prospective reimbursement
The Cost of and
Paying for Health
Care
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
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Policy
Premiums
Deductible
Co-insurance
Copayment
Fixed indemnity
Exclusion
Pre-existing condition
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
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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 lowrisk employees
Health Insurance Provided by the
Government
• Government health insurance plans only
available to select groups
• Medicare
• Medicaid
• Children’s Health Insurance Program
Medicare
• Covers more than 48 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 & coinsurance
• 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
• 53+ 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
• 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
• Other supplemental insurance
• 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
• 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)
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Closed-panel HMO
Open-panel HMO
Mixed model HMO
Staff model HMO
Independent practice associations (IPAs)
Types of Managed Care
• Other items related to HMOs
• Point-of-service (POS) option
• Medicare Advantage
• Medicaid and Managed Care
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
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
• Flexible spending accounts
• Medical Savings Accounts
• 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?