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HC Delivery Systems

Health Care Delivery Systems- Professional Practice

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
Created by: 1190550002
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