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COBH4030Chp13.pptxChapter 13
Health Care Delivery in the United States
Chapter Objectives (1 of 3)
After studying this chapter, you will be able to:
Define the term healthcare system.
Trace the history of healthcare delivery in the United States from colonial times to the present.
Discuss and explain the concept of the spectrum of healthcare delivery.
Distinguish between the different kinds of health care, including population-based public health practice, medical practice, long-term practice, and end-of-life practice.
List and describe the different levels of medical practice.
List and characterize the various groups of healthcare providers.
Explain the differences among allopathic, osteopathic, and nonallopathic providers.
Define complementary and alternative medicine.
Explain why there is a need for healthcare providers.
Prepare a list of the different types of facilities in which health care is delivered.
Chapter Objectives (2 of 3)
Explain the differences among private, public, and voluntary hospitals.
Explain the difference between inpatient and outpatient care facilities.
Briefly discuss the options for long-term care.
Explain what the Joint Commission does.
Identify the major concerns with the healthcare system in the United States.
Explain the various means of reimbursing healthcare providers.
Briefly describe the purpose and concept of insurance.
Define the term insurance policy.
Explain the insurance policy terms deductible, co-insurance, copayment, fixed indemnity, exclusion, and pre-existing condition.
Explain what is meant when a company or business is said to be self-insured.
Chapter Objectives (3 of 3)
List the different types of medical care usually covered in a health insurance policy.
Briefly describe Medicare, Medicaid, and Medigap insurance.
Briefly describe the Children’s Health Insurance Program (CHIP).
Briefly explain long-term care health insurance.
Define managed care.
Define the terms health maintenance organization (HMO), preferred provider organization (PPO), and point-of-service option.
Identify the advantages and disadvantages of managed care.
Define consumer-directed health plans and give several examples.
Provide a brief overview of the Affordable Care Act passed in 2010.
Summarize the three cases that have been heard by the U.S. Supreme Court that have had an impact on the Affordable Care Act.
Introduction
Healthcare delivery in U.S. is unlike other developed countries
Delivered by an array of providers in a variety of settings
Paid for in a variety of ways
Is U.S. health care a “system?”
History of Healthcare Delivery in the U.S. (1 of 2)
Self-care has been a category of health care throughout history and today
From colonial times through late 1800s, anyone trained or untrained could practice medicine
Past medical education not as rigorous as today
Early medical education not grounded in science; experience-based only, prior to 1870
History of Healthcare Delivery in the U.S. (2 of 2)
Most care was provided in patients’ homes
Hospitals only in large cities and seaports
Functioned more in a social welfare manner
Not clean; unhygienic practice
Almshouses
Pesthouses
Healthcare Delivery in the Late 1800s – Early 1900s (1 of 2)
Care moved from patient’s home to physician’s office and hospital
Building and staffing better; designed for patient care; trained people; medical supplies
Reduced travel time
Science had bigger role in medical education
Mortality decline due to improved public health measures
Healthcare Delivery in the Late 1800s – Early 1900s (2 of 2)
Early 1920s: chronic diseases passed communicable as leading causes of death
New procedures: X-ray, specialized surgery, chemotherapy, ECG
Training: doctors and nurses more specialized
1929 – 3.9% GDP on health care
Two-party system – patients and physicians
Physicians collected own bills, set and adjusted prices based on ability to pay
Healthcare Delivery – 1940s and 1950s
WWII impact
Due to wage restrictions, employers used health insurance to lure workers
Huge technical strides in 1940s and 1950s
Hill-Burton Act
Improved procedures, equipment, facilities meant rise in cost of health care
Concept of health care as basic right vs. privilege
Healthcare Delivery – 1960s
Late 1950s had overall shortage of quality care and maldistribution of healthcare services
Increased interest in health insurance
Third-party payment system became standard method of payment
Cost of health care rose
Increased access, little expense for those with insurance; those without unable to afford care
1965: Medicare and Medicaid
Healthcare Delivery – 1970s
Health Maintenance Organization Act of 1973
National Health Planning and Resources Development Act of 1974
Health Systems Agencies in place to cut costs and prevent building unnecessary facilities and purchasing unnecessary equipment
Healthcare Delivery – 1980s
Deregulation of healthcare delivery
Role of competition
Competitive market approach of questionable value in lowering healthcare costs
Proliferation of new medical technology
Elaborate health insurance programs
Healthcare Delivery – 1990s
American Health Security Act of 1993
Managed care
Achieve efficiency
Control utilization
Determine prices and payment
Mid-1990s – percentage of GDP and dollars spent on health care continued to increase
CHIP
Healthcare Delivery in the 21st Century
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
The World Health Report 2000 – Health Systems: Improving Performance
U.S. ranked 37 out of 191 countries
CHIP Reauthorization Act of 2009
Affordable Care Act of 2010
Healthcare System: Structure
Spectrum of healthcare delivery
Various types of care
Types of healthcare providers
Healthcare facilities in which health care is delivered
Spectrum of Healthcare Delivery
Population-based public health practice
Medical practice
Long-term practice
End-of-life practice
Public Health Practice
Interventions aimed at disease prevention and health promotion, specific protection, and case findings
Health education
Empowerment and motivation
Much takes place in governmental health agencies
Also occurs in a variety of other settings
Medical Practice
Primary medical care
Clinical preventive services; first-contact treatment; ongoing care for common conditions
Secondary medical care
Specialized attention and ongoing management
Tertiary medical care
Highly specialized and technologically sophisticated medical and surgical care
For unusual and complex conditions
Long-Term Practice
Restorative care
Provided after surgery or other treatment
Rehab care, therapy, home care
Inpatient and outpatient units, nursing homes, other settings
Long-term care
Help with chronic illnesses and disabilities
Time-intensive skilled care to basic daily tasks
Nursing homes and various settings
End-of-Life Practice
Services provided shortly before death
Hospice care
Terminal diagnosis
Variety of services and settings
Types of Healthcare Providers
12.4 million workers in U.S. (8.2% of pop.)
39% in hospitals; 26% in outpatient settings; 20% in nursing/residential facilities; 8% each in home health, laboratory, and other ambulatory care services
Over 200 types of careers in the industry
Independent providers
Limited care providers
Nurses
Physician Assistants
Allied healthcare professionals
Public health professionals
Independent Providers
Specialized education and legal authority to treat any health problem or disease
Allopathic and osteopathic providers
Nonallopathic providers
Allopathic and Osteopathic Providers
Allopathic providers
Produce effects different from those of diseases
Doctors of Medicine (MDs)
Osteopathic providers
Relationship between body structure & function
Doctors of Osteopathic Medicine (DOs)
Similar education and training
Most DOs work in primary care
Nonallopathic Providers
Nontraditional means of health care
Complementary and Alternative Medicine (CAM)
Used together with conventional medicine, therapy is considered “complementary”; in place of considered “alternative”
Chiropractors, acupuncturists, naturopaths, etc.
Natural products, mind-body medicine, manipulation, etc.
Limited (or Restricted) Care Providers
Advanced training in a healthcare specialty
Provide care for a specific part of the body
Dentists, optometrists, podiatrists, audiologists, psychologists, etc.
Nurses
Over 4 million working in nursing profession
Training and education of nurses
Licensed Practical Nurses (LPNs)
Registered Nurses (RNs)
Advanced Practice Registered Nurses (those with master or doctoral degrees)
Physician Assistants
Practice in many areas similar to physicians, but do not have MD or DO degrees
Training beyond RN, less than physician
Allied Healthcare Professionals
Assist, facilitate, and complement work of physicians and other healthcare specialists
Categories
Laboratory technologist/technicians
Therapeutic science practitioners
Behavioral scientists
Support services
Education and training varies
Public Health Professionals
Work in public health organizations
Usually financed by tax dollars
Available to everyone; primarily serve economically disadvantaged
Public health physicians, environmental health workers, epidemiologists, health educators, public health nurses, research scientists, clinic workers, biostatisticians, etc.
Healthcare Facilities and Their Accreditation
Physical settings where health care is provided
Inpatient care facilities
Patient stays overnight
Outpatient care facilities
Patient receives care and does not stay overnight
Inpatient Care Facilities
Hospitals, nursing homes, assisted-living
Hospitals often categorized by ownership
Private – profit making; specialty hospitals
Public – supported and managed by government jurisdictions
Voluntary – not-for-profit; ~½ of U.S. hospitals
Teaching and nonteaching hospitals
Full-service or limited-service hospitals
Outpatient Care Facilities
One where a patient receives ambulatory care
Variety of settings
healthcare practitioners’ offices, clinics, primary care centers, ambulatory surgery centers, urgent care centers, services offered in retail stores, dialysis centers, imaging centers
Group practices versus solo practices
Clinics
Clinics
Two or more physicians practicing as a group
Do not have inpatient beds
For-profit and not-for-profit
Some tax funded – created to meet needs of medically indigent
Federally Qualified Health Centers (FQHCs)
Other Types of Outpatient Facilities
Retail clinics at pharmacies
Urgent care centers
Ambulatory surgery centers
Non-hospital-based, specialty facilities
Rehabilitation Centers
Work to restore function
May be part of a clinic or hospital, or freestanding facilities
May be inpatient or outpatient
Long-Term Care Options
Nursing homes, group homes, transitional care, day care, home health care
Home health care
Growing due to restructuring of healthcare system, technological advances, and cost containment
Accreditation of Healthcare Facilities
Assists in determining quality of healthcare facilities
Process by which an agency or organization evaluates and recognizes an institution as meeting certain predetermined standards
The Joint Commission
Predominant accrediting organization
Healthcare System: Function
U.S. “system” unique compared to other countries
Affordable Care Act of 2010
Extends coverage
Curbs health insurance abuses
Initiates improvements in quality of care
Structure of the Healthcare System
U.S. structure – complex, expensive, many stakeholders, intertwined policies, politics
Major issues:
Cost containment, access, quality
All equally important; expansion of one compromises other two
Kissick, W.L. (1994). Medicine’s Dilemmas: Infinite Needs versus Finite Resources. Yale University Press. © 1994Reprinted by permission of Yale University Press
Access to Health Care (1 of 2)
Insurance coverage and generosity of coverage are major determinants of access to health care
2015 – 28.8 million uninsured (9.1%)
6.0 million fewer than in 2013 and 17.5 million fewer than in 2011
Likelihood of being uninsured greater for those: young, less education, low income, nonwhite, male
Greatest reason for lack of insurance: cost; followed by lost job or change in employment
Access to Health Care (2 of 2)
Lack of access to primary care
Factors that limit access are lack of health insurance, inadequate insurance, and poverty
Major component of Affordable Care Act is increasing the number of Americans with health insurance
Health insurance marketplaces – organizations established to create more organized and competitive markets for purchasing health insurance
Quality of Health Care (1 of 2)
Quality health care should be:
Effective
Safe
Timely
Patient centered
Equitable
Efficient
Groups that measure quality: AHRQ, NCQA
Quality of Health Care (2 of 2)
National Quality Strategy (NQS)
Mandated by ACA
Guided by three aims: better care, healthy people/healthy communities, affordable care
Accountable Care Organizations
Patient-Centered Medical Homes
The Cost of and Paying for Health Care (1 of 2)
In 2014, health expenditures: $3 trillion
U.S. biggest spender on health care in the world by total spent
Payments come from four sources:
Direct or out-of-pocket payments
Third-party payments from private insurance, governmental insurance programs, and other third-party payers
The Cost of and Paying for Health Care (2 of 2)
Reimbursement
Fee-for-service
Packaged pricing
Resource-based relative value scale
Capitation
Prospective reimbursement
Pay-for-performance
Centers for Medicare & Medicaid Services (2014). National Health Expenditure Data. Available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/index.html
Health Insurance
A risk and cost-spreading process, like other insurance
Cost is shared by all in the group
Generally “equitable,” but increased risk may lead to increased costs
Health Insurance Policy (1 of 2)
Health insurance policy
Premium
Deductible
Co-insurance
Copayment
Fixed indemnity
Exclusion
Pre-existing condition
Health Insurance Policy (2 of 2)
The Cost of Health Insurance
Cost of insurance mirrors cost of care
In U.S., burden falls primarily on the employer, then the employee
Increased worker share of premium
Raising deductibles
Increasing prescription co-payments
Increasing number of exclusions
Cost of policy determined by risk of group and amount of coverage provided
Self-Funded Insurance Programs
Programs created for/by employers rather than using commercial insurance carriers
Many benefits to the employer
Generally for larger companies, unless low-risk employees
Health Insurance Provided by the Government
Government health insurance plans only available to select groups
Medicare
Medicaid
Children’s Health Insurance Program
Medicare (1 of 2)
Covers more than 55.2 million people
Federal health insurance program for those:
65+, permanent kidney failure, certain disabilities
SSA handles enrollment
Contributory program through FICA tax
Four parts
Hospital insurance (Part A), medical insurance (Part B), managed care plans (Part C), prescription drug plans (Part D)
Medicare (2 of 2)
Part A – mandatory; has deductible & co-insurance
Part B – those in Part A automatically enrolled unless decline; has deductible & co-insurance
Part C – offered by private insurance companies; not available in all parts of U.S.
Part D – optional; run by insurance companies; monthly premiums; large number of plan available; complex to navigate
Uses DRGs
Medicaid
Health insurance program for low-income; no age requirement
68.8 million covered by Medicaid
Eligibility determined by each state; very costly budget item for states
Noncontributory program
CHIP
Created in 1997 and funded for 10 years
Reauthorized in 2009 through 2013
Funding assisted by increase in federal excise tax rate on tobacco
Targets low-income children ineligible for Medicaid
State/federal program
Problems with Medicare and Medicaid
Programs created to help provide health care to those who might have impossibilities of obtaining health insurance
Recurrent problems:
Some providers do not accept Medicare or Medicaid as forms of payment
Medicare/Medicaid fraud
Supplemental Health Insurance
Help cover out-of-pocket costs not covered through primary insurance
Medigap
Other supplemental insurance
Long-term care insurance
Preserve financial assets, prevent need for family or friends to provide care, enable people to stay independent longer, easier to go into facility of choice
The Henry J. Kaiser Family Foundation (2015). Medicaid and Long-Term Services and Supports: A Primer. Available at http://kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/
Managed Care
Goal to control costs by controlling healthcare utilization
Managed by MCOs
Have agreements with providers to offer services at reduced cost
Common features – provider panels, limited choice, gatekeeping, risk sharing, quality management and utilization review
Types of Managed Care (1 of 2)
Preferred provider organization (PPO)
Health maintenance organization (HMO)
Closed-panel HMO
Open-panel HMO
Mixed model HMO
Staff model HMO
Independent practice associations (IPAs)
Types of Managed Care (2 of 2)
Other items related to HMOs
Point-of-service (POS) option
Medicare Advantage
Medicaid and Managed Care
Other Arrangements for Delivering Health Care
National health insurance
A system in which the federal government assumes responsibility for healthcare costs of entire population; primarily paid for with tax dollars
U.S. only developed country without national healthcare plan
Seven failed attempts at national health care in U.S. over past 70+ years
Healthcare Reform in the United States (1 of 2)
Consumer-directed health plans (CDHPs)
Consumer responsibility for healthcare decisions with tax-sheltered accounts
Health savings accounts
Flexible spending accounts
Medical savings accounts
Affordable Care Act
Healthcare Reform in the United States (2 of 2)
Affordable Care Act
Three cases have been heard by the U.S. Supreme Court opposing components of the ACA
National Federation of Independent Businesses et al. versus Sebelius, Secretary of Health and Human Services
Burwell, Secretary of Health and Human Services, et al. versus Hobby Lobby Stores, Inc. et al.
King et al. versus Burwell, Secretary of Health and Human Services, et al.
Discussion Questions
How does payment for healthcare services affect the various types of healthcare providers now and in the future?
What changes will need to occur for all U.S. citizens to have affordable health insurance?
Will the Affordable Care Act effectively combat the numerous problems within the U.S. healthcare system?
