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 |