1

Health Care Delivery In USA

Moderator –Dr. P.R.DeshmukhPresenter – Dr. Revati

2

Framework Introduction

- History of USA healthcare system

- Health care status in USA Components of health care delivery system Provisions of Health care delivery Services Insurance & USA Public health System in USA Subsystem of US health System Health care delivery systems of other countries

3

The USA .. The United States is located –

• North American continent • Western Hemisphere.• 50 states • The total area is 9.7 million square km• Population - 313 million = 31 crores• 50% females

4

HISTORY Period Major Problems Impact on Health

19th and early 20th century

• Faecal contamination of water supplies• Under nutrition• Overcrowding, and Exhaustion due to industrialization

High prevalence of TB,

Enteric infections,

Acute respiratory diseases

Early 21st

• Overly rich diet, • Cigarette use, • Excessive alcohol consumption,• Too little physical activity,

New infectious diseases and

Major non-communicable diseases

5

Milestones in Medicine and medical educationYear Milestone

1700s Training under one physician - until hospitals were founded in mid 1700s .

1765 First medical school was established at Pennsylvania

1800s Only 4 medical schools in USA, no formal tuition, with no mandatory testing

1847 American Medical Association was established, to protect interest of providers,emphasized on standardizing medical education

1900s The medical professionals were - the general or family practitioners who practised solitary & 4% of GDP on medical care

2000 125 medical schools

6

Milestones of Hospital SystemYear Milestone1820 * Almshouses or Poorhouses - the precursors of hospitals

* Pesthouses * First Hospitals were built around urban areas of New York, Boston .. * Dispensaries or pharmacies - free care and medicines to poor

1850 Hospital system was developed

1920 Development of advanced medical technology

1970 The first Patient Bill Of Rights was introduced

1980 87% hospitals offered Ambulatory surgery , EMTALA was inacted ,

1990 Medicare reimbursement system – by federal government

7

Milestones in Public HealthYear Milestones

1700-1800 –* Us public health practices targeted reducing epidemics * Some of public health departments were set up

1800- 1900 •Britans (UK) Edwin Chadwick Report – stimulated similar survey in US * John Snow activities - Developed State Public Health Law – ,, Foundation For Public Health Activities

1900- 1950 Public health Departments in most of the states .

1980- 1990 Recognised first cases of AIDS

1990-2000 - After September 11 , 2001 terrorist attack – The Public Health Security and Bio Terrorism Preparedness. and Response Act 2002 came forward

8

Milestones of US Health Insurance System Year Milestones

1800-1900 1847 – Massachusetts Health Insurance Co. Of Boston was first insurer to issue - Sickeness Insurance

1900-1920 Kimball began a hospital insurance plan for school teachers in Texas - Model for Blue Cross Plans

1940- 50 * Blue Cross Commission – created national network of doctors- . . . * 57% population had hospital insurance – 1950

1965 Medicare and Medicaid Programs signed into Law

1990-2000 Children's health insurance programme was implemented

2010 President Obama Signed Obama Care (Patient Protection and Affordable Care Act ). .

9

Health Status In USA

Indicator & Health Conditions 1990- 2000 2010 -latest

1 Life expectancy at birth 70 (M ) /77 ( F ) 76 (M ) /81 ( F )

2 IMR 17 6

3 NMR 17 4

4 MMR 12 28

4 Diabetes ( % in age grp >20 yrs) 9.1 11.5

5 Obesity BMI >/ 30 ( % in age grp >20 yrs) 22.9 33.5

6 Hypertension ( % in age grp >20 yrs) 25.5 31.2

10

Health status Between 2000 and 2010Death Rate/morbidity From 2000 - 2010

Health conditions leading to death / Morbidity – status compared 2000- 2010

Males Increased Alzheimer’s disease -38% ,

Decreased Stroke -37%, Heart disease -30%, Cancer -16%, Chronic lower respiratory diseases- 13%,

Females Increased Alzheimer’s disease - 41%.

Decreased Stroke - 35%, Heart disease - 32%, and Cancer - 12%,

11

Introduction

• The U.S. Health system’s origin and functions were strongly influenced by Europe

• The United States has a unique system of health care delivery- complex and massive.

• Most developed countries have National Health Insurance Programs referred to as “Universal Access” which is not there in USA. “Universal Access” is

Provide routine and basic health care Run by the government and financed through general taxes.

– All Americans are not “entitled” to basic health care services

12

The Role players in Health Care DeliveryEducation/Research

• Medical schools• Dental schools• Nursing programs• Physician assistant programs• Nurse practitioner programs• Physical therapy,• Occupational therapy • speech therapy progrm• Research organizations Private foundations• US Public Health Professional associations• Trade associations

Suppliers PharmaceuticalcompaniesMultipurposesuppliersBiotechnologycompanies

Insurers Managed careplansBlue Cross/Blue Shield plansCommercialinsurersSelf-insuredemployersMedicareMedicaidVA

Providers Preventive CareHealth departmentsPrimary CarePhysician officesCommunity healthcentersDentistsNonphysician providersSubacute CareSubacute care facilitiesAmbulatory surgerycentersAcute CareHospitalsAuxiliary

Payers Blue Cross/Blue Shield plansCommercial insurersEmployersThird-partyadministratorsState agencies

Government Public insurancefinancingHealth regulationsHealth policyResearch fundingPublic health

13

Basic Components of a Health Services Delivery System

Health care delivery ystem incorporates four functional components—financing, insurance, delivery, and payment, or the quad-function model.

14

Distribution of Hospitals in USA

56

17

5

22

Non-Profit

Profit

Federal Government

local government

15

Provision of Health Care Services

• Insured individuals tend to enter the health-care system through a Primary Care Provider, with some kinds of insurance (e.g. PPO) or person may go directly to a specialist.

• Uninsured individuals often do not have a regular primary care provider, but instead visit Community Health Centres (which provide primary care for low-income, uninsured and minority populations) and Hospital Emergency Rooms for their health care. Due to out-of-pocket costs they may not be able to seek out specialty, surgical or inpatient care unless they need emergency care.

• Emergency departments in hospitals that receive payment from Medicare (which is nearly all hospitals in the US) are required by law to provide care to anyone needing emergency treatment until they are stable.

16

Outpatient services: primary care

• Ambulatory health service settings, are - the offices of physicians, dentists, and other health practitioners, medical and diagnostic laboratories, and home health care service locations.

• Most primary care physician private practices are physician-run and / or owned

• Primary care practitioners (physicians, nurse midwives) are generalists who coordinate patients’ care and see patients over an extended period of time , So Specialists have also being included in Primary Care

• The specialty fields of primary care are family medicine, internal medicine, paediatrics, obstetrics and gynaecology

17

Outpatient services: primary care• Primary care practices in private clinics provide care to patients who are insured or

who can afford substantial OOP expenses.

• Patients receive all types of primary care service, including screening, diagnosis and treatment for chronic and acute conditions, with the exception of health promotion and education, which tend to be neglected in some physician practices .

• Around 20 million people in the United States receive their primary care in approximately 1200 CHCs in 6000 urban and rural areas

• Patient inability to pay for care is one of the chief barriers to primary care in the United States

18

Outpatient services: primary care …

There are several venues for the delivery of primary care :-

• Private clinic of physicians

• The public or non-profit community health centre- provides access to primary care for low-income, uninsured, and minority populations

• Other government settings include clinics for the military (such as those run by the VHA), prisons,, and centres for migrants and the homeless

19

Outpatient services: primary care …

• Urban public and teaching hospitals may also have outpatient clinics for primary care services, typically serving underserved populations

• A small number of integrated care systems, such as Kaiser Permanente and Geisinger Health System, provide primary care as part of their integrated systems which cover primary, specialty, emergency, hospital and other care

• Workplace wellness programmes and retail clinics (in pharmacies or large stores) are providing some primary care services by providing screening, health promotion and basic prevention services

•

20

Health Care Services.....

• More acute-care services, such as surgery, being performed on an outpatient basis

• The informal caregiver (usually family or friends) plays an important role in United States health care; 23% of Americans provide some form of informal care.

• Pharmaceuticals are highly utilized in the United States

• The use of complementary and alternative medicine (CAM) is also growing in the United States.

21

The Continuum of Health Care ServicesHealth Services Services provider

Preventive care Public health programs, Community programs, Personal lifestylesPrimary care settings

Primary care Physician’s office or clinic, Community health centers, Self-careAlternative medicine

Specialized care Specialist provider clinics

Chronic care Primary care settings,Specialist provider clinics, Home healthLong-term care facilities, Self-care, Alternative medicine

Rehabilitative care Rehabilitation departments ,(hospitals, long-term care facilities)

End-of-life care Hospice services provided in a variety of settings

22

Role of government in health care system

Powers in the health sector are divided between the federal and state governments.

• States - fund and manage many public health functions, pay part of the cost of Medicaid and shape its organization within that state, and set the rules for some health insurance policies

• On the other hand, products such as pharmaceuticals and medical devices are regulated at federal level.

• Regulations to achieve, objectives of quality, access and cost control in health care may be set by public or private entities, at any or all of federal, state or local level

23

Insurance & USA• There were 194.5 million Americans with private health insurance coverage

• The US government finances health benefits for certain special populations:-

• The program for the elderly and certain disabled individuals is called Medicare.

• The program for the indigent, jointly administered by the federal government and state governments, is named Medicaid.

• The program for children from low-income families, another federal/ state partnership, is called the Children’s Health Insurance Program (CHIP).

• In 2009, there were 43.4 million Medicare beneficiaries and 47.8 million Medicaid recipients, but 50.7 million people (16.7%) remained without any health insurance

24

Medicare & Medicaid • In 1965, the first major federal health insurance programmes, Medicare and Medicaid, were

established

• Medicare covered Americans aged 65 and older,• • Part A: Hospital Insurance was social insurance funded by payroll taxes• Part B: Supplemental Medical Insurance, covered outpatient and physicians visits and, although

voluntary, was purchased by nearly all seniors since 75% of the premiums was paid from general federal revenues.

• Medicaid covered about half Americans with low incomes & was a welfare model

• Only those who met both income and eligibility criteries could receive the coverage, which was provided free of patient charges

• Medicaid is jointly funded by the federal and state governments

25

Blue Cross

• Private health insurance in the US begin by 1930s, with the non-profit Blue Cross plans for hospital care, and soon thereafter Blue Shield plans for physician care.

• Blue Cross aimed for hospital coverage on the part of workers and employers on the one hand, and the need for a steady revenues on the part of hospitals

• Enrollees to have the freedom to choose their own hospital.

• It was non-profit , as hospitals guaranteed the provision of services, which was possible because of empty beds

26

Blue Shield plans

• Blue Shield plans that covered physicians’ services were established under similar principles: non-profit status and free choice of provider.

• It began to encounter competition from commercial (for-profit) insurers, using “experience rating” (where premiums vary based on the past health status of the insured group), so Blues had to switch too, for-profit organizations

• More Americans obtained their hospital insurance from commercial insurers rather than Blue Cross .

27

Affordable Care Act (ACA) of 2010 Its adoption was highly controversial and its content reflects the general American

preference for minimal government intervention.

Improving coverage is a central aim, & nearly all individuals needed to have some form of health insurance.

• Improved coverage is done through:-• subsidies for the uninsured to purchase private insurance• underinsurance, - providing greater protection for persons - If insurance is,

inadequate or cancelled once they become ill• increased funds for primary care to improve access & for Public health strengthening• incentives for efficiency and better-quality care plus penalties linked to inefficient care• and political, economic, and social variables might change both the substance and the

timetable

28

Organization of Public Health System

• Public health is promoted mostly through public agencies, primarily at the state level, but some private agencies also play a role

• At the federal level, Public health services are headed by the United States Public Health Service (USPHS), a division of the HHS. ( Health And Human Services)

The USPHS is comprised of eight agencies listed in:-• Agency for Toxic Substances and Disease Registry (ATSDR)• Agency for Healthcare Research and Quality (AHRQ)• Centers for Disease Control and Prevention (CDC)• Food and Drug Administration (FDA)• Health Resources and Services Administration (HRSA)• Indian Health Service (IHS)• National Institutes of Health (NIH)• Substance Abuse and Mental Health Services Administration (SAMHSA)

29

Organization of Public Health System

• Many public health functions are delegated to local public health agencies (usually called “health departments”) within that jurisdiction which can be at the county, city, town or township .

• Most local health departments (60%) are at the county level, 18% cover a city, town or township, 11% are joint city–county jurisdictions, and 9 per cent are multicounty.

31

The Surgeon General in US The United States does not have a single National Health Policy Act.

The country’s Surgeon General has set national voluntary objectives in the Healthy People Initiative

It is a set of ideal objectives that began in the late 1970s.

• Every 10 years the Surgeon General develops and publishes a list of goals for the United States health-care system and evaluates progress over the previous 10 years.

• Healthy People 2020 was unveiled in December 2010 by President Obama’s Secretary of Health and Human Services

• It has four overall goals relating to higher quality and longer life, health equity, improving social and physical environments, and promoting health behaviours

• There is no seperate funding to meet the Healthy People objectives, to be met with existing funds

32

Subsystems of US Health Care Delivery

• Managed Care

• Military

• Vulnerable Populations

• Integrated Delivery

33

Characteristics Of The U.S. Health Care System

1. No central agency governs the system.

2. Access to health care services is selectively based on insurance coverage.

3. Health care is delivered under imperfect market conditions.

4. Third-party insurers act as intermediaries between the financing and delivery functions.

5. The existence of multiple payers makes the system cumbersome.

6. The balance of power among various players prevents any single entity from dominating the system.

7. Legal risks influence practice behavior of physicians.

8. Development of new technology creates an automatic demand for its use.

9. New service settings have evolved along a continuum.

10. Quality is no longer accepted as an unachievable goal.

34

3.9

17.7

35

US Healthcare spending

Hospital Care $ 882.3 BillionPhysician & Clinical $ 565.0 BillionProfessional Service $ 76.4 BillionDental $ 110.9 BillionPersonal Care $ 138.2 BillionHome Health Care $ 77.8 BillionNursing Facilities $ 151.5 BillionPrescription Drugs $ 263.3 BillionMedical Equipment $ 95.0 Billion

36

Strengths

• It has a large and well-trained health workforce, and a wide range of high-quality medical specialists, as well as secondary and tertiary institutions,

• A robust health sector research program and, for selected services, among the best medical outcomes in the world.

• Relatively short wait-time for treatment

• Government directly covers the population through health care programs -for the elderly, disabled, military service families and veterans, children, and some of the poor

37

The Problem

• Millions of uninsured (~48 million Americans) with inadequate care

• Increasing premium amounts

• Health care cost is very high

• Inequitable distribution of resources and outcomes & incomplete coverage

• Patients with pre-existing conditions were denied insurance or had to pay heft premiums

• Age-related disparities in healthcare

38

Patient Protection and Affordable Care Act (Obamacare)

• ObamaCare is the unofficial name for The Patient Protection and Affordable Care Act which was signed into law on March 23, 2010 by President Barack Obama.

• Aimed at reforming the American health care system. ObamaCare’s main focus is on providing more Americans with access to affordable health insurance, improving the quality of health care and health insurance, regulating the health insurance industry, and reducing health care spending in the US.

• It offers Americans a number of new benefits, rights, and protections in regards to their healthcare, and setting up a Health Insurance Marketplace (HealthCare.Gov) where Americans can purchase federally regulated and subsidized Health Insurance during open enrollment. The law also expands Medicaid, improves Medicare, requires you to have coverage in 2014 and beyond, and contains some new taxes and tax breaks, among other things.

39

Patient Protection and Affordable Care Act Obamacare)• Every year during an annual open enrollment period folks can obtain coverage through

the health insurance marketplace, or Shop Outside Of The Marketplace. This year open enrollment starts on November 1st, 2015 and ends January 31st,2016.

• The Patient Protection and Affordable Care Act contains nine titles, each addressing an essential component of reform:

• Quality, affordable health care for all Americans • The role of public programs • Improving the quality and efficiency of health care • Prevention of chronic disease and improving public health • Health care workforce • Transparency and program integrity • Improving access to innovative medical therapies • Community living assistance services and supports • Revenue provisions

41

Health Care Systems of Other Countries Models for structuring the National Health Care Systems:

1 ) National Health Insurance (Canada uses this system )• the government finances health care through general taxes but Core of care delivered by private providers

2 ) National Health Systems ( Great Britan uses this system] In additional to financing a tax-supported national health insurance program:

• government manages the infrastructure for the delivery of medical care• most medical institutions are operated by government• most health care providers like - physicians are government employees

3) Socialized Health Insurance Systems (Germany uses this style)• Health care is financed through, government-mandated contributions by employer and employees• Health care delivered by private providers• Private not-for profit insurance companies, called sickness funds, are responsible for collecting the

contributions and paying physicians and hospitals• Government exercises overall control

42

References WHO ,. Health Systems in Transition, United States of America: Health System Review 2013; secretariat

of, the European Observatory on Health Systems and PolicieS; Vol. 15 No. 3 2013. Available from • www.euro.who.int/__data/assets/pdf.../HiT-United-States-of-America.pdf

• The commonwealth fund. ( The U.S. Health System in Perspective: A Comparison of Twelve Industrialized Nations ( homepage on internet); July2011. Available from ww.commonwealthfund.org/.../Issue%20Brief/2011/.../1532_Squires_

• OECD); Health at a Glance 2013 OECD INDICATORS ( homepage on internet ); 2013 . Available from • http://dx.doi.org/10.1787/health_glance-2013-en

Overview of the US Healthcare Delivery System , Jones and Bartlett Publishers, LLC ( homepage on internet).No date. Available from . WWW.samples.jbpub.com/9781449615192/69840_CH01_Niles.pdf

• Lance H. Rose, LFACHE and Rachel V. Rose1 . the united states, canada, and the united kingdom – a comparative analysis of healthcare policies and their impact on the elderly , Journal of International Aging Law & Policy [Vol. IV } 2010