An Overview of US Health Care Delivery - Jones & Bartlett …

1 Chapter 1. An Overview of US Health care Delivery Learning Objectives To understand the basic nature of the US Health care system To outline the key functional components of a Health care Delivery system To get a basic Overview of Health care reform and the Affordable care Act To discuss the primary characteristics of the US Health care system To emphasize why it is important for Health care practitioners and managers to understand the intricacies of the Health care Delivery system To get an Overview of Health care systems in selected countries To point out global Health challenges and reform efforts To introduce the systems model as a framework for studying the Health services

2 System in the United States The US Health care Delivery system is a behemoth that is almost impossible for any single entity to manage and control. 1. 1 13/01/14 2:57 PM. 2 CHAPTER 1 An Overview of US Health care Delivery Overview presented here introduces the Introduction reader to several concepts treated more The United States has a unique system of extensively in later chapters. Health care Delivery unlike any other Health care system in the world. Most devel- oped countries have national Health insur- An Overview of the Scope and Size ance programs run by the government and financed through general taxes. Almost all of the System citizens in such countries are entitled to Table 1 1 demonstrates the complexity of receive Health care services.

3 Such is not yet Health care Delivery in the United States. the case in the United States, where not all Many organizations and individuals are Americans are automatically covered by involved in Health care , ranging from edu- Health insurance. cational and research institutions, medical The US Health care Delivery system is suppliers, insurers, payers, and claims pro- really not a system in its true sense, even cessors to Health care providers. Multitudes though it is called a system when reference of providers are involved in the Delivery of is made to its various features, components, preventive, primary, subacute, acute, auxil- and services. Hence, it may be somewhat iary, rehabilitative, and continuing care .

4 An misleading to talk about the American increasing number of managed care orga- Health care Delivery system because a true nizations (MCOs) and integrated networks system does not exist (Wolinsky 1988). One now provide a continuum of care , covering main feature of the US Health care system many of the service components. is that it is fragmented because different The US Health care Delivery system people obtain Health care through different is massive, with total employment that means. The system has continued to undergo reached over million in 2010 in various periodic changes, mainly in response to con- Health Delivery settings. This included over cerns regarding cost, access, and quality.

5 838,000 professionally active doctors of Describing Health care Delivery in the medicine (MDs), 70,480 osteopathic physi- United States can be a daunting task. To cians (DOs), and million active nurses facilitate an understanding of the struc- (US Census Bureau 2012). The vast number tural and conceptual basis for the Delivery of Health care and Health services profes- of Health services, this text is organized sionals ( million) work in ambulatory according to a systems framework presented Health service settings, such as the offices of at the end of this chapter. Also, for the sake physicians, dentists, and other Health prac- of simplicity, the mechanisms of Health ser- titioners, medical and diagnostic laborato- vices Delivery in the United States are col- ries, and home Health care service locations.

6 Lectively referred to as a system throughout This is followed by hospitals ( million). this text. and nursing and residential care facilities The main objective of this chapter is ( million). The vast array of Health to provide a broad understanding of how care institutions includes approximately Health care is delivered in the United States. 5,795 hospitals, 15,700 nursing homes, and Examples of how Health care is delivered 13,337 substance abuse treatment facilities in other countries are also presented. The (US Census Bureau 2012). 2 13/01/14 2:57 PM. An Overview of the Scope and Size of the System 3. Table 1 1 The Complexity of Health care Delivery Education/Research Suppliers Insurers Providers Payers Government Medical schools Pharmaceutical Managed care Preventive care Blue Cross/ Public insurance Dental schools companies plans Health departments Blue Shield plans financing Nursing programs Multipurpose Blue Cross/ Primary care Commercial insurers Health Physician assistant suppliers Blue Shield plans Physician offices Employers regulations programs Biotechnology Commercial Community Health Third-party Health policy Nurse practitioner companies insurers centers administrators Research programs Self-insured Dentists State agencies funding Physical therapy.

7 Employers Public Health Nonphysician providers occupational Medicare Subacute care therapy, speech Medicaid Subacute care facilities therapy programs VA. Ambulatory surgery Research Tricare centers organizations Acute care Private foundations Hospitals US Public Health Service (AHRQ, Auxiliary Services ATSDR, CDC, FDA, Pharmacists HRSA, IHS, NIH, Diagnostic clinics SAMHSA) X-ray units Professional Suppliers of medical associations equipment Trade associations Rehabilitative Services Home Health agencies Rehabilitation centers Skilled nursing facilities Continuing care Nursing homes End-of-Life care Hospices integrated Managed care organizations integrated networks 3 13/01/14 2:57 PM.

8 4 CHAPTER 1 An Overview of US Health care Delivery In 2011, 1,128 federally qualified The market-oriented economy in the Health center grantees, with 138,403 full- United States attracts a variety of private time employees, provided preventive and entrepreneurs driven by the pursuit of prof- primary care services to approximately its obtained by carrying out the key func- million people living in medically under- tions of Health care Delivery . Employers served rural and urban areas (HRSA 2013). purchase Health insurance for their employ- Various types of Health care professionals ees through private sources, and employ- are trained in 159 medical and osteopathic ees receive Health care services delivered schools, 61 dental schools, over 100 schools by the private sector.

9 The government of pharmacy, and more than 1,500 nursing finances public insurance through Medi- programs located throughout the country care , Medicaid, and the Children's Health (US Bureau of Labor Statistics 2011). Mul- Insurance Program (CHIP) for a significant titudes of government agencies are involved portion of the low-income, elderly, dis- with the financing of Health care , medical abled, and pediatric populations. However, research, and regulatory oversight of the insurance arrangements for many publicly various aspects of the Health care Delivery insured people are made through private system. entities, such as Health maintenance orga- nizations (HMOs), and Health care services are rendered by private physicians and hospitals.

10 The blend of public and private A Broad Description of the System involvement in the Delivery of Health care US Health care Delivery does not func- has resulted in: tion as a rational and integrated network of components designed to work together a multiplicity of financial arrangements coherently. To the contrary, it is a kalei- that enable individuals to pay for Health doscope of financing, insurance, deliv- care services;. ery, and payment mechanisms that remain numerous insurance agencies or MCOs loosely coordinated. Each of these basic that employ varied mechanisms for functional components financing, insur- insuring against risk;. ance, Delivery , and payment represents multiple payers that make their own an amalgam of public (government) and determinations regarding how much to private sources.