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Chapter 9
Health Care Delivery Systems
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Introduction
• Radical changes in
health care delivery
related to:
– Explosion of scientific
knowledge
– Integration of
technology in health
care
– Emphasis on health
promotion
– Resource limitations
– Shortages of health care
professionals
• Health care delivery
systems provide:
– Primary care for health
promotion, illness
prevention
– Secondary care for
treatment toward early
detection, cure of illness
– Tertiary care for chronic
rehabilitative, end-of-life
services
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Challenges of Health Care Delivery in the
21st Century
• Health Care Access
– World Health Organization (WHO)
• Established as United Nations Unit (UN) whose
efforts included:
• Eradication of infectious diseases, provision of
health services for mothers, children
• World Health Assembly
• Expanded initiatives to promote, coordinate
social, economic efforts to promote general
health, welfare of all people
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Challenges of Health Care Delivery in the
21st Century (cont’d)
• Health Care Access
– WHO and UNICEF
• Affirmed that health, health care were
fundamental human rights
• Emphasized that social, economic development
were key to supporting health care initiatives
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Challenges of Health Care Delivery in the
21st Century (cont’d)
• Health care funding
– National health service model
• Funds health care by guaranteeing access to
health care services through national health
insurance plan usually funded by general tax
revenues
• United Kingdom, Canada, Japan adopted this
model
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Challenges of Health Care Delivery in the
21st Century (cont’d)
• Health Care Funding
– Mandated insurance model
• Requires compulsory universal health care
insurance
• Nonprofit insurance funds provide resources for
persons, employers to purchase health insurance
• Germany, Brazil, Italy, Jamaica, South Africa
adopted this model
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Challenges of Health Care Delivery in the
21st Century (cont’d)
• Health Care Funding
– Entrepreneurial insurance model
• Consists of voluntary health insurance coverage
that relies on purchase of health insurance by
individuals
• Employers provide group coverage, employees pay
part of insurance premium
• United States, China, South Korea, Mexico,
Nigeria, India adopted this model
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Challenges of Health Care Delivery in the
21st Century (cont’d)
• United States
– Federal-, state-sponsored programs provide access
to all citizens who lack resources to buy health
insurance
• Medicare
• Medicaid
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Challenges of Health Care Delivery in the
21st Century (cont’d)
• Health care work force
– World Health Report
• Critical shortages of physicians, nurses, midwives
by 2020
• Projected growth of elderly, aging workforce
• Increased need, use of nurse practitioners for
primary care services because of high cost
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Question
• Which agency helped to expand the belief that health
care is a fundamental human right?
A. United States government
B. American health care agencies
C. World Health Organization
D. Pharmaceutical companies
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Answer
• C. World Health Organization
• Rationale: WHO and UNICEF held a joint conference at
Alma-Ata during which a declaration was issued that
affirmed that health and health care were fundamental
human rights.
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Selected Current Health Care Delivery
Systems
• U.S health care delivery system
– American health care system influenced by European
models
– 1873: formal nursing education began
– 19th century: most American physicians had only
high school education, minimal apprenticeship
– Early American hospitals were places where socially
marginal fragments of society resided
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Selected Current Health Care Delivery
Systems (cont’d)
• Scientific advancements
– Mid-to-late 1800s: scientific discoveries revolutionized
health care
• Anesthesia, antisepsis, germ theory, improved hygiene
• Thermometer, ophthalmoscope, laryngoscope
• Gastroscope, cystoscope, hypodermic needle,
sphygmomanometer
• Hospitals became places of healing rather than death
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The American Health Care Delivery
System
• Health care becomes flourishing industry
– Hospital-owned schools of nursing
– Apprenticeship approach dominated nursing, medical
education
– Medical education moved to university settings
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The American Health Care Delivery
System (cont’d)
• Health care in early 20th century
– Physicians
• High profits made by providing services to
wealthy, private patients who could afford them
• Public institutions met health care needs of poor
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The American Health Care Delivery
System (cont’d)
• Health care in early 20th century
– American Medical Association (AMA)
• Restructured, to assure physicians financial
security, power through their own organization,
reform of medical education
• Eliminated competition from other people as
health care providers
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The American Health Care Delivery
System (cont’d)
• Health care in early 20th century
– Impact of illness on worker productivity
• Montgomery Ward and Company: first insurance
plan, provided group insurance for illness, injury
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The American Health Care Delivery
System (cont’d)
• Health care in early 20th century
– Effects of war, poverty
• Increased governmental provision, funding of
health care
• Accident and life insurance, first hospitalization
insurance plan, Blue Cross, The McCarran–
Ferguson Act, antibiotics, blood transfusions,
rehabilitation
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The American Health Care Delivery
System (cont’d)
• Health care in mid-to-late 20th century
– Information explosion
– Chronic disease prevalence with development of
complex regimens to control them
– Department of Health Education and Welfare
• Formed to provide mechanism to coordinate health
research, service programs
– Emphasis on research, technology led to
specialization, depersonalization
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The American Health Care Delivery
System (cont’d)
• Health care in mid-to-late 20th century
– Increasing health care costs
• Prospective payment set prearranged
reimbursement amount by diagnosis-related
groupings (DRGs)
• Increased profits could be made resulting in
business approach to health care
• Managed care
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The American Health Care Delivery
System (cont’d)
• Health care in mid-to-late 20th century
– Economic downslide of 1980s led to job loss,
insurance loss
• Consolidated Omnibus Budget Reconciliation Act
(COBRA)
– Health care expenditures rose close to twice rate of
inflation in 1990, 1995, 2001, 2002
• Expected to increase to 19.3% of gross domestic
product (GDP) by 2019
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American Health Care Costs
• Health Care Costs in the United States Today
– Currently over 15% of US’s GDP goes toward health
care
– Health care expenditures fall into these categories:
• Health-related research, facility construction,
payment for personal health care services,
supplies
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Provider Costs
• American hospital costs surpass those of all developed
nations
– Increased use of highly technical equipment,
expensive medications
– Threat of malpractice suits
– Physician income in United States (on average) is 1.5
to 3 higher than physicians in other developed
countries
• Services rendered by APRN’s cost substantially less,
consumers report high satisfaction
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Insurance
• 2011 Census
– 49.9 million uninsured persons in United States
• 249 million Americans were underinsured
– Employer based health insurance coverage fell to
55.3% in 2010
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Patient Protection and Affordable Care Act
of 2010
• Federal and state governments assume a larger role in
providing health insurance
• Bundled payment
• Medical home
• Accountable Health Care Organization
• Insurance exchange
• Comparative effectiveness research
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The Canadian Health Care Delivery
System
• Canada adopted different forms of health care delivery
– Historical development:
• Rising health care costs resulted in federal efforts
to provide coverage for health expenditures for
everyone
• Canada Health Care Act of 1984 resulted in
provincial administration of health care programs
• All Canadians have equal access to specific list
of health care services under provincial policy
plans
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The Canadian Health Care Delivery
System (cont’d)
• Principles
– Public, nonprofit authority administers provincial
health insurance plans, answers to provincial
government
– Each plan covers all medically necessary services
citizens may need from physicians, hospitals
– Plans provide reasonable access to health services
without discrimination
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The Mexican Health Care Delivery System
• Mexicans have equal access to health care services but
there is disparity between affluent, poor
– Affluent purchase health care
– Workers covered through social security system or
employer-based plan
– Poor rely on public services system
• Emphasis shifted to health promotion rather than disease
treatment for public health services
– Increased access to health care services for poor
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Question
• Is the following statement true or false?
• Malpractice litigation and physician’s income are factors
that have driven the increased cost of health care
services in the United States.
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Answer
• True
• Rationale: Increased profits resulted in a business
approach to health care, threat of malpractice suits, and
physician income have all created an increase in health
care costs in the United States.
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Comparing and Contrasting the Selected
Health Care Delivery Systems
• Health care concerns vary by country
– Developing nations
• Malnutrition, infants and children mortality,
communicable diseases
• Wealthy, developed nations
• Diseases of affluence (obesity, chronic diseases
such as diabetes mellitus and degenerative joint
diseases)
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Comparing and Contrasting the Selected
Health Care Delivery Systems (cont’d)
• United States
– Highest concentration of physicians, pharmacists,
managerial, and support staff
• Canada
– Highest concentration of nurses
• Citizens of United States, Canada tend to be satisfied
with health care services they receive
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Health Care Delivery Settings
• Primary care options
• The hospital industry
• Integrated health care delivery systems: A choice for
today’s consumer
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The Interdisciplinary Health Care Team
Client
Pharmacists
Third-party payer
Board of Directors
Paramedical personnel
Utilization review
Chief Executive Officer
Social Workers
Spiritual support services
Medical staff
Therapists
Human resources
Nursing staff
Health Information Service
Foundation
Case manager
Business manager
Alternative care
Dietitians
Central product services
Linen services
Biomedical engineering services
Housekeeping services
Quality Management
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Nursing Care Delivery Models
• System used by nurses to organize and deliver nursing
services to best meet client needs
• Comparison of nursing care delivery system models
– Case
– Functional
– Team
– District
– Primary
– Case management
– Client-focused care
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Nursing Challenges Related to Health Care
Delivery Systems
• Practical Challenges
• Nursing Shortage
• Ethical challenges
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Summary and Significance to Practice
• Health care delivery systems
– Massive structural change, reorganization
• Raises multiple ethical, practical considerations
• Nurses
– Assume leadership in shaping future health care
delivery by using cognitive skills, compassion so all
people will have access to optimal health care
services
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