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HC Delivery Systems
Health Care Delivery Systems- Professional Practice
| Question | Answer |
|---|---|
| Broad Definition of Health Services Delivery | Major components of the system & processes that enable people to receive health care |
| Restricted Definition of Health Services Delivery | the act of providing health care to patients |
| Primary Objectives of a Health Care System | 1. Enable all citizens to receive health care services 2. Deliver services that are cost-effective & meet established standards of quality |
| How is the U.S. Health Care system unique? | Not a system No universal HC financed by taxes No entitlement No other country operates like the U.S. Changes due to cost, access & quality |
| Numbers about the HC System | 200.9 million Americans with private insurance 43 million Medicare beneficiaries 42.6 million Medicaid recipients 46.3 million (15.4%) uninsured |
| Financing & Insurance Mechanisms | Employer-based health insurance (private) Privately-purchased health insurance (private) Gov't programs (public) |
| What is there little or none of in the U.S. Health Care system? | Networking Interrelated components Standardization Coordination Cost containment as a whole Planning/Direction |
| External Forces on the U.S. Health Care System | Political Climate Economic development Technological Progress Social & cultural values Physical environment POpulation characteristics Global influences |
| 10 characteristics- No Central Agency | Most developed nations have nat'l HC where every citizen is entitled to receive a set of service; To control costs, use global budget to determine total HC expenses; U.S. has mostly private financing/delivery |
| 10 characteristics- No Central Agency | Private HC, hospitals, physicians are independent of gov't; No one monitors total expenses through global budgets/utilization; Gov't sets standards of participation through policy/regs; Providers comply w/ standards to be certified to provide Medicaid/ |
| 10 characteristics- Partial Access | Access limited to those who: Have insurance through employer Covered under gov't HC plan Can afford insurance out of pocket Can pay at time of service privately Insurance helps ensure access |
| 10 characteristics- Partial Access | Those unable to pay wait until a health problem arises then receive HC at ER- hospital gets no payment Primary care: basic & routine |
| 10 characteristics- Imperfect Market | In nat'l HC, economic markets don't exist Private HC consolidating, forming alliances & integrating delivery system (networks) |
| 10 characteristics- Imperfect Market | Pts & providers act independently Prices set by interaction of supply/demand Unrestrained competition on basis of price & quality Pts must have info of availability of different services |
| 10 characteristics- Imperfect Market | Pts have info on price & quality on each provider Pts muts bear cost of services received Pts make decisions about purchase of HC services |
| Imperfect Market- Item Pricing | Obtain fees charged for service (surgeon's price) Services can't be determined prior to procedure |
| Imperfect Market- Package Pricing | Bundled fee for a group of related services |
| Imperfect Market- Capitation | All HC services include one set fee per person, more all-encompassing |
| Phantom Providers | Bill for services separately i.e. 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 |
| 10 characteristics- Third Party Insurers & Payers | Pt is 1st first party Provider is 2nd party Intermediary is 3rd party- wall of separation b/t financing & delivery; quality of care is a secondary concern |
| 10 characteristics- Multiple Payers | U.S. has many payers, company can choose different plans (billing & collection nightmare; system becomes more cumbersome) Single-payer system (nat'l HC system usually the primary payer-gov't) |
| 10 characteristics- Power Balancing | Multi Players- physicians, administration, insurance, gov't, employers Fragmented self-interests- prevents an entity from dominating |
| 10 characteristics- Legal Risks | U.S. is a litigious society Practitioners engage in defensive medicine- prescribe dx tests, return checkups, documentation |
| 10 characteristics- High Technology | U.S., a hotbed of research & innovations Creates demand for new services despite high costs With capital investments, must have utilization Legal risks for providers denying new technology |
| 10 characteristics- Continuum of Services | Medical servies has 3 broad categories: Curative, Restorative, Preventative HC isn't confined to the hospital |
| 10 characteristics- Quest for Quality | Continuous quality improvement Higher expectations Quality standards with compliance |
| Govt's Roles in the U.S. Health Service System | Major financier of HC delivery Determine reimbursement rates to providers who render Medicare/Medicaid services Regulates through licensing personnel & HC establishments Health policy |
| Blended Public & Private U.S. HC System | Results: Multi financial arrangements Many insurance companies w/ different risk mechanisms Many payers with different determinates Many consulting firms offering: planning, cost containment, quality, minimizing resources |
| Functional Components of HC delivery | Financing- buy insurance or paying for HC services consumed usually employer-based Insurance- to protect vs. catastrophic risk; determine package the individual is eligible to receive |
| Quad Function Model- 4 components | Financing Insurance Delivery Payment |
| Functional Components of HC Delivery | Delivery- Provider: any entity that delivers HC services & receives insurance payment directly for those services Payment- reimbursement:how much to pay for service; funds come from premium paid to insurance co.; pt usu. pays co-pay, insurance pays rest |
| Even if employed, employees may not have insurance because...? | 1. Employers not mandated to offer insurance; premium cost sharing (rarely paid at 100% if at all); benefit: group rate or availability of insurance 2. Participation in insurance is voluntary |
| Why are people uninsured? | Unemployed Employers not req'd to offer insurance Employees not req'd to buy insurance Don't fit elibitility of gov't programs |
| National HC Programs | Theoretically, no one is uninsured Universal access: is managed by gov't & provides a defined set of HC services to all citizens |
| National Health Insurance | Gov't financed through taxes, rendered by private providers Requires gov't consolidation of financial, insurance & payment Gov't manages infrastructure- medical institutions operated by gov't Tax-supported |
| Socialized Health Insurance | Financed through gov't-mandated contributions by employers & employees HC delivered by private providers |
| Trends & Directions | Illness>Wellness Acute>Primary Care IP>OP Ind. Health>Community Fragmented>Managed Care Independent institutions>Integrated systems Service Duplication>Continuum |
| Why is the U.S. HC system not really a "system"? | Fragmented nature- components like financing, insurance, delivery, & payment aren't interrelated |
| Dualism | Gov't & private enterprise involved in: financing, organization, delivery of health services In gov't, power comes from the constitution; In free enterprise, it comes from profit |
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