the us healthcare system and the roemer model lecture 2 tracey lynn koehlmoos, phd, mha hsci 609...
TRANSCRIPT
The US Healthcare Systemand the Roemer Model
Lecture 2Tracey Lynn Koehlmoos, PhD, MHA
HSCI 609 Comparative International Health Systems
Organization of the US Health Services System
• Ever shifting mix of public/government sector, private sector and voluntary services.
• 16% of GDP spent on health services (2005)
• The US government now:– Major payer for care: Medicare, Medicaid– Provider of healthcare for special populations like
Tricare, Indian Health Services, VA– Major supporter of education and training of
many types of care providers
Introduction to the Roemer Model
• Developed by Milton I. Roemer, MD, MPH• WHO, UCLA School of Public Health• Pioneer in international health systems
research• Roemer Model of Health Services System
(1984) allows for clear understanding of health systems
Clear understanding = Meaningful comparisons
DELIVERYOF
SERVICES
ORGANIZATION OF
PROGRAMS
MANAGEMENT
ECONOMICSUPPORT
RESOURCEPRODUCTION
Roemer Model
Five Parts to the Model
• Organization of the Program
• Management of Health Services System
• Economic Support of Health Services
• Production of Health Services Resources
• Delivery of Health Services
Part 1: Organization
• Ministry of Health—all levels
• Other Public Agencies
• Voluntary Agencies
• Enterprises
• Private Market
Part 2: Management
• Planning
• Administration
• Regulation
• Legislation
Part 3: Economic Support
• Personal Households
• Charity
• Insurance (voluntary)
• Social Security
• Governmental
• Revenues
• Foreign Aid
Part 4: Production of Resources
• Manpower
• Facilities
• Commodities (drugs, DME, equipment, etc.)
• Knowledge
Part 5: Delivery of Services
• Primary Care—Prevention
• Primary Care—Treatment
• Secondary Medical Care
• Tertiary Medical Care
• Care of Special Disorders and Populations
Applying Roemer at Home
• Part I: Organization of Health Services:
• US health system is DECENTRALIZED
• Department of Health and Human Services (DHHS) instead of MoH
• DHHS regulates and finances many health services
• Services delivery primarily occurs in private sector
Part I: Organization
• Public Health at the national level
• Centers for Disease Control and Prevention
• Food and Drug Administration
• Centers for Medicare and Medicaid
• National Institutes of Health
• Agency for Healthcare Research and Quality
Part I: Organization
• Voluntary Agencies • Gap fillers
– Disease or interest group specificACS, ARC, AARP
– Professional associationsAPHA, AHA, AMA
– Philanthropic and religious organizations Robert Wood Johnson
Part I: Organization
• Private Market
• Most health services provided in the private market
• Most health insurance provided in the private market
• Pharmaceuticals and supplies (developed and sold)
• Health professional training
Part 2: Management
• Planning: No centralized national-level planning authority
• Administration: More applied in nature at project or program level
• Legislation: all government units have authority to enact laws (budgeting process, restriction and limitations, new programs
• Regulation: Implementation of laws, licensure, certification, accreditation
Part 3: Economic Support• Private Health Insurance (voluntary and
employment related) largest source of funds (34%) to US health services
• ~70% of <65 have some type of health insurance
• Household/Out of Pocket: 15%• Medicare: 17%• Medicaid: 16%
• $1.3 trillion in 2000• 16% of GDP in 2005
Part 3: Economic Support• Where does the money go?
• 33% hospitals (50% of this from Fed.)
• 23% physician services
• 10% drugs
• 9% other personal care
• 7% nursing homes
• 6% program administration
• 3% research and construction
• 2% home health care
Part 4: Production of Resources
• Manpower: Health Services Industry– Largest Industry in US: 11.9 million workers– 800,000+ physicians
• 270.6 per 100,000 population• 2:1 Specialist to Generalist practitioners • Medicare subsidized training (GME/residencies)
– 2 million+ nurses: shortage, training variations– Pharmacists, dentists, RT, OT, PT– Health Administrators
Part 4: Production of Resources
• Hospitals: – Various categories (I, II, III) & structures– Merge and integrate to expand scope– Financial challenges, cost shifting – Prospective Payment, negotiated rates
• Biomedical Research and Technology:– US most advanced on planet/ cost driver– Drugs developed in private sector/FDA approval– Most research publicly funded (via NIH)– No clear chain of dissemination/assessment
Part 5: Delivery Systems
Continuum of Care• Prevention and Promotion: Public Sector• Early Detection: Public and Private• Primary Care: Private sector; PCP• Secondary Care: Specialists/hospitals• Tertiary Care: Academic Health Center• Long Term Care: Medicaid is big payer• Palliative Care: Home or Hospice Medicare $ for
80%• Outside the continuum: chronic mental illness
DELIVERYOF
SERVICES
ORGANIZATION OF
PROGRAMS
MANAGEMENT
ECONOMICSUPPORT
RESOURCEPRODUCTION
Roemer Model
Conclusion
• Applying the Roemer Model to the US Healthcare System gives us a means to understand the system and make meaningful and direct comparisons.
• Skyrocketing costs, an aging population & a high percent of uninsured are issues of concern
• Quality-Access-Cost remain the overarching values of concern for the US healthcare system