63800_CH01_Final.qxd:Shi Chapter 1 Major Characteristics of U.S. Health Care Delivery INTRODUCTION The United States has a unique system of health care delivery. For the purposes of this discussion,...

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Which of the characteristics or components (define at least two) health care delivery system have the most significant impact on the health care delivery system in the United States? What makes these more impactful than the other 8 characteristics

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63800_CH01_Final.qxd:Shi Chapter 1 Major Characteristics of U.S. Health Care Delivery INTRODUCTION The United States has a unique system of health care delivery. For the purposes of this discussion, “health care delivery” and “health services delivery” can have slightly different meanings, but in a broad sense, both terms refer to the major components of the system and the processes that enable people to receive health care. In a more restricted sense, the terms refer to the act of providing health care services to patients. The reader can identify which meaning is intended by paying attention to context. In contrast to the United States, most developed countries have national health insurance programs that are run by the government and financed through general taxes. Almost all of the citizens in such countries are enti- tled to receive health care services that include routine and basic health care. These countries have what is commonly referred to as universal access. All American citizens, on the other hand, are not entitled to routine 63800_CH01_Final.qxd:Shi 2/9/09 12:54 PM Page 1 © Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION. 2 Chapter 1 • Major Characteristics of U.S. Health Care Delivery and basic health care services. Although the U.S. health care delivery sys- tem has evolved in response to concerns about cost, access, and quality, the system has been unable to provide universally a basic package of health care at an affordable cost. One barrier to universal coverage is the unneces- sary fragmentation of the U.S. delivery system, which is perhaps its central feature (Shortell et al., 1996); however, the enormous challenge of expand- ing access to health care while containing overall costs and maintaining expected levels of quality continues to intrigue academics, policy makers, and politicians. To make learning the structural and conceptual bases for the delivery of health services easier, this book is organized by the systems framework, which is presented at the end of this chapter. One of the main objectives of Chapter 1 is to provide a broad understanding of how health care is deliv- ered in the United States. The following overview introduces the reader to several concepts that are treated more extensively in later chapters. The U.S. health care delivery system is complex and massive. Interestingly, it is not actually a system in the true sense, although it is called a system when its various features, com- ponents, and services are referenced. Hence, it may be somewhat mislead- ing to talk about the American health care delivery “system” (Wolinsky, 1988, p. 54), but the term will nevertheless be used throughout this book. Organizations and individuals involved in health care range from edu- cational and research institutions, medical suppliers, insurers, payers, and claims processors to health care providers. Total employment in various health delivery settings is almost 14.4 million, including professionally active doctors of medicine (MDs), doctors of osteopathy (DOs), active nurses, dentists, pharmacists, and administrators. Approximately 382,000 physical, occupational, and speech therapists provide rehabilitation services. The vast array of institutions includes 5,700 hospitals, 15,900 nursing homes, almost 2,900 inpatient mental health facilities, and 11,000 home health agencies and hospices. Close to 800 programs include basic health services for migrant workers and the homeless, community health centers, black lung clinics, human immunodeficiency virus (HIV) early interven- tion services, and integrated primary care and substance abuse treatment programs. Various types of health care professionals are trained in 144 medical and osteopathic schools, 56 dental schools, 109 schools of pharmacy, and more than 1,500 nursing programs located throughout the country. 63800_CH01_Final.qxd:Shi 2/9/09 12:54 PM Page 2 © Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION. Subsystems of U.S. Health Care Delivery 3 There are 201.7 million Americans with private health insurance coverage, 40.3 million Medicare beneficiaries, and 38.3 million Medicaid recipients. Health insurance can be purchased from approxi- mately 1,000 health insurance companies and 70 Blue Cross/Blue Shield plans. The managed care sector includes approximately 405 licensed health maintenance organizations (HMOs) and 925 preferred provider organizations (PPOs). A multitude of government agencies are involved with the financing of health care, medical and health services research, and regulatory oversight of the various aspects of the health care deliv- ery system (Aventis Pharmaceuticals, 2002; Bureau of Primary Health Care, 1999; National Center for Health Statistics, 2007; U.S. Bureau of the Census, 1998; U.S. Census Bureau, 2007; Bureau of Labor Statistics, 2008). SUBSYSTEMS OF U.S. HEALTH CARE DELIVERY The United States does not have a universal health care delivery system enjoyed by everyone. Instead, multiple subsystems have developed, either through market forces or the need to take care of certain population seg- ments. Discussion of the major subsystems follows. Managed Care Managed care is a system of health care delivery that (1) seeks to achieve efficiency by integrating the basic functions of health care delivery, (2) employs mechanisms to control (manage) utilization of medical services, and (3) determines the price at which the services are purchased and, conse- quently, how much the providers get paid. It is the most dominant health care delivery system in the United States today and is available to most Americans (for more details on managed care, please refer to Chapter 9). The employer or government is the primary financier of the managed care system. Instead of purchasing coverage from a traditional insurance company, the financier contracts with a managed care organization (MCO), such as an HMO or a PPO, to offer a selected health plan to employees. In this case, the MCO functions like an insurance company and promises to provide health care services contracted under the health plan to the enrollees of the plan. 63800_CH01_Final.qxd:Shi 2/9/09 12:54 PM Page 3 © Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION. 4 Chapter 1 • Major Characteristics of U.S. Health Care Delivery The term enrollee (member) refers to the individual covered under the plan. The contractual arrangement between the MCO and the enrollee— including the collective array of covered health services that the enrollee is entitled to—is referred to as the health plan (or “plan” for short). The health plan uses selected providers from whom the enrollees can choose to receive routine services. Primary care providers or general practitioners typically manage routine services and determine appropriate referrals for higher level or specialty services, often earning them the name of gate- keeper. The choice of major service providers, such as hospitals, is also limited. Some of the services may be delivered through the plans own hired physicians, but most are delivered through contracts with providers such as physicians, hospitals, and diagnostic clinics. Although the employer finances the care by purchasing a plan from an MCO, the MCO is then responsible for negotiating with providers. Providers are typically paid either through a capitation (per head) arrange- ment, in which providers receive a fixed payment for each patient or employee under their care, or a discounted fee. Providers are willing to dis- count their services for MCO patients in exchange for being included in the MCO network and being guaranteed a patient population. Health plans rely on the expected cost of health care utilization, which always runs the risk of costing more than the premiums collected. By underwriting this risk, the plan assumes the role of insurer. Figure 1.1 illustrates the basic functions and mechanisms that are nec- essary for the delivery of health services within managed care. The key functions of financing, insurance, delivery, and payment make up the quad- function model. Managed care arrangements integrate the four functions to varying degrees. Military The military medical care system is available free of charge to active- duty military personnel of the U.S. Army, Navy, Air Force, and Coast Guard and also to certain uniformed nonmilitary services such as the Public Health Service and the National Oceanographic and Atmospheric Association (NOAA). It is a well-organized, highly integrated system. It is comprehensive and covers preventive as well as treatment services that are provided by salaried health care personnel, many of whom are themselves in the military or uniformed services. This system combines public health 63800_CH01_Final.qxd:Shi 2/9/09 12:54 PM Page 4 © Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION. Subsystems of U.S. Health Care Delivery 5 with medical services. Routine ambulatory care is provided close to the military personnel’s place of work at the dispensary, sick bay, first-aid sta- tion, or medical station. Routine hospital services are provided at base dis- pensaries, in sick bays aboard ship, and at base hospitals. Complicated hospital services are provided in regional military hospitals. Long-term care is provided through Veterans Administration (VA) facilities to certain retired military personnel. Although patients have little choice regarding how services are provided, in general, the military medical care system provides high-quality health care. Families and dependents of active-duty or retired career military per- sonnel are either treated at the hospitals or dispensaries or are covered by Employers Government–Medicare, Medicaid Individual self-funding FINANCING Insurance companies Blue Cross/Blue Shield Self-insurance INSURANCE Insurance companies Blue Cross/Blue Shield Third-party claims processors PAYMENT Physicians Hospitals Nursing homes Diagnostic centers Medical equipment vendors Community health centers DELIVERY (Providers) Access Risk underwriting Capitation or discounts Utilization controls Integration of functions through managed care (HMOs, PPOs) Figure 1.1 Managed Care: Integration of Functions 63800_CH01_Final.qxd:Shi 2/9/09 12:54 PM Page 5 © Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION. 6 Chapter 1 • Major Characteristics of U.S. Health Care Delivery TRICARE, a program that is financed by the military. This insurance plan permits the beneficiaries to receive care from private medical care facilities as well as military ones. The VA health care system is available to retired veterans of previous military service, with priority given to those who are disabled. The VA sys- tem focuses on hospital care, mental health services, and long-term care. It is one of the largest and oldest (1946) formally organized health care sys- tems in the world. Its mission is to provide medical care, education and training, research, contingency support, and emergency management for the Department of Defense medical care system. It provides health care to more than 5.5 million persons at over 1,100 sites, including 153 hospitals, 732 ambulatory and community-based clinics, 135 nursing homes, 209 counseling centers, 47 domiciliaries (residential care facilities), 73 home health care programs, and various
Answered Same DayOct 29, 2019Swinburne University of Technology

Answer To: 63800_CH01_Final.qxd:Shi Chapter 1 Major Characteristics of U.S. Health Care Delivery INTRODUCTION...

David answered on Nov 30 2019
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y Cleavon Battie
Submission date: 30-Oct-2017 12:28AM (UTC-0400)
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