Objectives
• Gain broad understanding of how health care
is delivered in the United States
• Learn main characteristics of U.S. health care
delivery system
• Recognize differences between U.S. health
care delivery system and national health
programs of most developed countries
• Learn of U.S. health care delivery subsystems
• What is health care
delivery?
• What is a health care
delivery system?
U.S. Health Care Delivery:
A Systems Framework
• Health care delivery in the United States
– Is based upon a foundation of historical, cultural,
social, and economic factors
– Consists of a logical arrangement of various
interrelated and interdependent components
– Demonstrates a progression from “inputs” to
“outputs”
– Despite appearances, it is not an accident!
U.S. Health Care Delivery: A Systems Framework
(Adapted from Shi & Singh, 2013)
Inputs
Human
Resources
Structure & Processes
Outputs
Outpatient &
Primary Care
Long-term &
Post-acute
Care
Inpatient &
Acute Care
Underserved Populations
Cost
Access
Quality
Technology
Managed Care & Health Networks
Policy &
Reform
Financing
Historical Factors
Cultural, Social,
& Economic Factors
System Foundations
U.S. Health Care System:
The Main Characteristics
• The U.S. health care system is unique in
comparison to the health care systems of
other developed countries
• Ten main areas of distinction
❶ No central governing agency,
Little integration and coordination
• Not centralized
• Complex and costly
• A variety of payment, insurance, and delivery
mechanisms
• Large role of private sector
• Limited but important role of federal & state
governments
0
Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).
6.8
6.8
7.3
7.4
7.6
7.7
8.1
8.2
8.4
8.5
8.7
8.7
8.9
8.9
9.1
5.7
5.9
9.2
9.3
9.6
9.8
16.0
Public expenditure
6.4
9.9
10.1
10.1
10.2
10.4
10.8
11.0
9.8
10
United States
France
Switzerland
Germany
Belgium1
Canada
Austria
Portugal
Netherlands1
Denmark
Greece
Iceland
New Zealand2
Sweden
Norway
OECD
Italy
Australia
Spain
United …
Finland
Japan
Slovak…
Ireland
Hungary
Luxembourg3
Korea
Czech…
Poland
Mexico
Turkey
Health Expenditures by OECD Country
(Percent of GDP)
20
Private expenditure
15
5
❷ Technology driven,
Focused on acute care
• Center of medical research & innovation
– Creates growth in demand for new services
– Negative outcomes accompany benefits
• Is the latest or most high-tech solution
always the best?
• Would increased emphasis on primary care
prevent acute conditions requiring high-tech
intervention?
❸ High on cost,
Unequal in access,
Average in outcome
• The U.S. spends more than any other
developed country on health care
• Despite rising expenditures, many residents
have limited access to basic care
• Despite rising expenditures, the U.S. lags
behind other developed nations in numerous
population health measures
Health Expenditures by OECD Country
Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).
Health Expenditure Growth Trends
(% of GDP)
Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).
Life Expectancy vs. Health Spending
Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).
❹ Imperfect market conditions
•
•
•
•
•
•
The payer is not always the patient
Competition is restrained
Patients are not always well-informed
Information is difficult to obtain
Patients do not directly bear service costs
Patients’ ability to make decisions is limited
❺ Government as subsidiary to
private sector
• Dominant private sector
– Built upon American traditions
• Government spending fills in the gaps
– Environmental protections
– Support for research & training
– Care for vulnerable populations
❻ Market justice vs. social justice:
Conflict throughout health care
• U.S. health care system involves a fusion of
these two principles
• Differing views of how to distribute care
– Ability vs. need
• What might be the consequences of a system
that favors market justice? Or social justice?
❼ Multiple players &
Balance of power
• U.S. health care involves multiple players
• Self-interests of players are often at odds
• What might be the consequences of a system
with competing interests and voices?
– Good? Bad?
• Is reform possible?
❽ Quest for integration
& accountability
• Efforts in the U.S. to promote primary care as
the organizing hub for continuous,
coordinated, and comprehensive services
• Emphasizes patient-provider relationships as
a means to improve individual and
population
• Patient-provider relationships also require
accountability
❾ Access to health care services is
selectively based on insurance
• Access is granted to individuals who:
–
–
–
–
Have health insurance through employers
Are covered under government programs
Can afford to buy insurance with private funds
Can pay for services privately
• What are options for the uninsured?
❿ Legal risks influence
practice behaviors
• “Litigious society”
• Private health care providers are increasingly
becoming more susceptible to litigation
– Risk of malpractice lawsuits
– Costs of time, money, reputation, etc.
– Defensive medicine a way to avoid litigation
Comparing to Health Care Systems of
Other Developed Countries
• National health care programs with universal
access
• Three basic national health care system
models
– National Health Insurance (e.g., Canada)
– National Health System (e.g., Great Britain)
– Socialized Health Insurance System (e.g.,
Germany)
Models of Health Care Delivery
• Bismarck Model
– Sickness funds financed jointly by employers &
employees
• Beveridge Model
– Health care provided & financed by government
through taxes
• National Health Insurance Model
– Government insurance purchases care from private
providers
• Out of Pocket Model
– If you have the resources, you can pay for care
U.S. Health Care Delivery Subsystems
• In contrast to a universal health care delivery
system, multiple subsystems have developed
to comprise the U.S. health care delivery
system
– Managed care
– Military
– Vulnerable populations
– Integrated delivery
U.S. Health Care Delivery Subsystems
• Managed care
– Developed to contain health care costs &
expenditures
– Seeks to achieve efficiency by integrating basic
functions of health care delivery
– Employs mechanisms to control or manage
utilization of medical services
– Determines the price at which services are
purchased and how much providers are paid
– Most dominant health care delivery system in U.S.
U.S. Health Care Delivery Subsystems
• Military
– Available free-of-charge to active-duty military
personnel
– Well-organized, highly integrated system
– Combines public health with medical services
– In general, the military medical care system
provides high-quality health care
U.S. Health Care Delivery Subsystems
• Vulnerable populations
– Poor, uninsured, minority or immigrant status
– Live in geographically or economically
disadvantaged communities
– Receive care from “safety net” providers
– Without safety net providers, patients have to
forego care or seek care in hospital emergency
departments (if one exists nearby)
– Subsystem faces enormous pressure
U.S. Health Care Delivery Subsystems
• Integrated delivery
– The hallmark of U.S. health care industry over the
past decade – and becoming larger
– Organizational integration to form integrated
delivery systems (IDS) or networks
– Strategic linkages among hospitals, physicians, and
insurers
– Objective: have one health care organization
deliver a range of services
U.S. Health Care Delivery Subsystems
• Long Term Care
– Medical and nonmedical care that is provided to
individuals who are chronically ill or who have a
disability.
– Health care and support services for daily living
– Not covered by Medicare
– LTC insurance is offered separately, but it can be
expensive
– Expected to have more integration with the acute
care system
U.S. Health Care Delivery Subsystems
• Public Health System
– Improve and protect community health
• Monitoring health status
• Diagnosing and investigating, informing and educating
health problems and hazards
• Developing policies
• Enforcing laws and regulations
• Assuring competent professional health workforce
• Research
What We’ve Learned
• The U.S. health care delivery system is unique
– Characterized by a patchwork of subsystems
– Differs considerably from systems of other
developed countries
– May be viewed according to a systems framework
to generally understand the various system
components and features