chapter 1 powerpoint .pptx
TRANSCRIPT
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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 U S Health Care Syste!
• $he health care wor#force e!ploys over13 4 !illion people
• 565,777 active 8Ds• 97,457 DO)s• - 3 !illion nurses• ,9; hospitals• 1 ,977 nursin' ho!es• 1,1-5 health centers• 677< !edical, dental and phar!acy schools• 1, 77< nursin' pro'ra!s
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$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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$he U S Health Care Syste!
• $here)s little or no: – networ#in' –
interrelated co!ponents – standardi ation – coordination –
cost contain!ent as a whole – plannin', direction
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$he U S Health Care Syste!
• Has: – duplication – overlap – inade0uacy – inconsistency – waste – co!ple2ity – ine ciency – %nancial !anipulation – fra'!entation
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$he U S Health Care Syste!
• 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 $hird party insurers are inter!ediaries between
%nance and delivery8ultiple payers are cu!berso!e
3 "alance of power, no do!ination9 Be'al ris# a/ects practice behavior5 ew technolo'y creates de!and for its use; ew service settin's alon' a continuu!17 Euality is achievable
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$en Characteristics thatDi/erentiate
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
$en Characteristics thatDi/erentiate
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*
$en Characteristics thatDi/erentiate
the U S Health Care Syste!
$ 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
$en Characteristics thatDi/erentiate
the U S Health Care Syste!
$ 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
$en Characteristics thatDi/erentiate
the U S Health Care Syste!
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$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'
$en Characteristics thatDi/erentiate
the U S Health Care Syste!
$ 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*
$en Characteristics thatDi/erentiate
the U S Health Care Syste!
$ 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
$en Characteristics thatDi/erentiate
the U S Health Care Syste!
$ 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
$en Characteristics thatDi/erentiate
the U S Health Care Syste!
$ 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'
$en Characteristics thatDi/erentiate
the U S Health Care Syste!
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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
the U S Health Care Syste!
$ 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
$en Characteristics thatDi/erentiate
the U S Health Care Syste!
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@overn!ent)s &oles in the U SHealth Service Syste!• 8ajor %nancier of health care
delivery• Deter!ine rei!burse!ent rates to
providers who render 8edicare 8edicaid services
• &e'ulates throu'h licensin'personnel and health careestablish!ents
• Health policy
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$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