Agustin, Charlene B. Bongalon, Roxanne V. Bundoc, Janine C. Divinagracia, Almarie Joyce L. Talaue, Harold S.

Health Care Delivery System of USA

Introduction
U.S. health care system -best health care system in the world - spends more on health care than any other country in the world

Characteristics of USA Healthcare Delivery System

1. No Central Governing Agency; Little Integration and Coordination

Not centrally controlled and therefore has a variety of payment, insurance, and delivery mechanism, and health care is financed publicly and privately 55% of the fund is from the Private sectors 45% is from the Government

2. Technology Driven and Focusing on Acute Care

Growth in science and technology often creates a demand for new services despite shrinking resources to finance sophisticated care Contribute to increased in demand for expensive technological care Hospitals compete on the basis of having the most modern equipment

3. High on Cost, Unequal in Access, and average in Outcome

$1.988 trillion allotted to healthcare delivery system in 2005 , 1/6 dollars spent in economy Many US residents have limited access to even the most basic care

Access is restricted to:

Have health insurance through their employers Covered under a government health care program Can afford to buy insurance out of their own private funds Able to pay services privately

4. Imperfect Market Condition 5. Government as Subsidiary to the private sector 6. Market Justice Vs. Social justice

7. Multiple Players and Balance of power

Key players in the System: 1. Physicians 2. Administrators of health service institutions 3. Insurance companies 4. Large employers 5. Government Each player has a different economic interest to protect

8. Quest for Integration and Accountability

There is a drive to use primary care as the organizing hub for continuous and coordinated health services

9. Access to Health Care is Selectively based on Insurance 10. Legal Risks influence Practice Behaviors

Subsystems of US Health Care Delivery

Managed Care Military Vulnerable Population

Managed Care
1. Seeks to achieve efficiency by integrating the basic functions 2. Employs mechanism to control utilization of medical services 3. Determines the price at which the services are purchased.

Health Maintenance Organizations (HMOs)

Unique feature of US health system. Within the private system in US only. Physicians work for HMOs.

 HMO contract with separate physicians group to provide its service. Pre- paid group practice (PPGP). Individual Practice Association.

Figure 1. Basic Functions and mechanism for the delivery of Health services within Managed Care

Military medical care system

Provide high-quality services Available free of charge to active duty military personnel of the U.S. Army, Navy, Air force, and Coast Guard. Also with Public Health Service and the National Oceanographic and Atmospheric Association Covers preventive as well as treatment services

TRICARE
Financed by the military Insurance plan for the beneficiaries to receive care from private medical care facilities as well as military ones

Veterans Administrations
Federally administered program for veterans of the military. Priority: Disabled Health care is delivered in

government-owned VA hospitals and

clinics.

VA Health Care System

Focuses: - Hospital Care - Mental Health Services - Long Term Care Is one of the largest and oldest(1946) formally organized health care system in the world.

SUBSYSTEM FOR VULNERABLE POPULATION

Who are the Vulnerable Population?

Poor Uninsured/ Minority Immigrant Status Live in geographically/economically disadvantaged communities and receive care from safety net providers.

safety net providers

Providers include the health centers, physicians' offices, and hospital outpatient department, emergency depepartment They are expressly designed to serve the underserved.

Bureau of Primary Health Care (BPHC)

Located in Health Resource and Services Administration in the department of Health and Human Services (DHHS) Provides federal support for community based health centers that include programs for:

- Migrant and seasonal farm workers and their families - Homeless persons - Public housing residents - School aged children

Subsystem for Vulnerable Population

Medicare Medicaid State Childrens Health Insurance Program (SCHIP)

Medicare
-only entity that performed the function of reimbursement program administered by the government - One of the largest sources of health insurance in the country, serving nearly 39 million

Three basic categories of beneficiaries:

Individuals age 65 and older Individuals who are permanently and completely disabled, Individuals diagnosed with end-stage renal disease

Financed by:
federal income taxes- a payroll tax shared by employers and employees, and individual enrollee premiums

Managed by:
Health Care Financing Administration (HCFA) which is another division of DHHS

Four major components

PART PART PART PART A- hospital services B- physician services C- medicare advantages D- prescription drug benefit

PART- A
Coverage:

mandatory for all eligible beneficiary:

Short-stay hospital inpatient services,

Skilled nursing facilities,

Home health services, and

Hospice care.

Financing for part- A:

Medicare Trust Fund Out of pocket deductible for hospital care. Fixed amount for an episode of

care.

PART - B
Covers physician care and other outpatient services. Optional benefit Beneficiaries are responsible for paying a monthly premium. Exposed to significant out-of-pocket costs, including deductibles, copayments, and costs for non-covered services.

Part C:
covers an array of managed care plans an alternative to the traditional Medicare program.

Medicare +Choice program.

Part D: Medicare Prescription Drug Plan

Provide coverage for brand name and generic prescription drugs at pharmacies in the program As part of the Medicare Modernization Act of 2003 and Effective during 2006.

 Provide coverage for brand name and generic prescription drugs or unexpected presumption bills in the future.

Medicaid:
Third largest source of health insurance in the country Jointly financed and administered by the federal government and individual state governments.

Beneficiary:
Poor/ low income Elderly Disabled individuals Children Pregnant Women Parents of young children Estimating to 12% of the population

Minimum services covered

Inpatient and outpatient medical care Physician services Laboratory and imaging services Family planning services Mental health services

 Early childhood diagnostic screening and treatment services, and Selected long-term care services including nursing home care and home health care.

Optional services
Rehabilitation care Dental care Home Community-based long-term care services.

Table.3: Medicaid coverage on the basis of eligibility in year 2009

Total beneficiaries Aged 65 or above Blind or disabled

56.0 Million 6.5% 14.0%

Adult in the family of 22.6% dependent children

Children < 21 years Others

48.4% 8.55%

Figure 3. Overall Medicaid coverage

Figure 4: Health insurance coverage among children < 18 years of age.

SCHIP: State Childrens Health Insurance Program

Established in 1997. For low-income children not eligible for the traditional Medicaid program but has a modest income (states may differ rules regarding eligibility)

 Uninsured children who reside in families with incomes below 200% of the FPL or whose family has an income 50% higher than the states Medicaid eligibility threshold.

 Jointly financed and administered by the federal government and individual state governments.

 For little or no cost, the insurance pays for the childs: - Physician visits - Immunization - Hospitalization - Emergency room visits

Health-Care Purchasers

Health Care Purchaser

Private Health Insurance
Employer supported Self supported Medicare

Government Health Insurance

Medicaid

SCHIP

VA

Private Health Insurance:

Employer-sponsored insurance Principle mode Part of the benefits package for employees.

Administration
Private companies, both for-profit (e.g. Aetna, Cigna) and non-for-profit (e.g. Blue Cross/Blue Shield).

Self-Insured Company: Pay for all health care costs incurred by employees directly (general motors).

Private non-group (individual market):

Population that is self-employed or retired.

Health Care Workforce:

Table.2: Number of physician and Dentist per 10,000 populations (2010)

Human Resource Active physician

Number per 10,000 27.4

Physician in patient care 25.4 Dentist 6

Table.1: Health Care Expenditure pattern (2010):

Total health care expenditure Health Consumption Expenditure Hospital services Professional Services Other health residential care Home Care Nursing Care and continuing care

100 93.7 30.5 27.1 4.9 2.7 5.5

Medical Product
Govt. Admn. Govt. Health Insurance Govt. public health Investment: Research Structure and equipment

13.2
1.2 5.4 3.1 6.3 1.8 4.5

Figure 1: Personal Health Care Expenditure by type of expenditure (2009).

USA: Public Health System:

Public Healths Three Core Functions

Assurance
Policy Development

Assessment

The Ten Essential Services

Source: Wallace RB, Kohatsu N. editors. Maxcy- Rosenue Last: Public Health
and Preventive Medicine. 15th ed. New York; The Mac Graw hill Company: 2008. P1217- 50.

Unique feature of US public health system

Council on Linkages between Public Health Practice and Academia:

public health practice de-coupled

from its academic base. to facilitate additional activities that would enhance the practice/academic connection

Organizations under the Public Health System:

National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC) Health Resources and Services Administration (HRSA),

 Indian Health Service (IHS), Food and Drug Administration (FDA), Agency for Toxic Substances

 Disease Registry (ATSDR) (administered by the CDC) Substance Abuse and Mental Health Administration (SAMHA)

The state public health role:

Assessment of the health needs in the state based on statewide data

collection:
Assurance of an adequate statutory base for health activities in the state Establishment of statewide health objectives, delegating power to locals as appropriate and holding them accountable Assurance of appropriate organized statewide effort to develop and maintain essential, personal, educational, and environmental health services; Provision of access to necessary services; and solution of problems inimical to health Guarantee of a minimum set of essential health services Support of local service capacity.

National Health Care

Obama Care

Health Care Reform: 2010 (Obama Care)

Long history of Reform in US.

Patient protection and Affordable care bill (PPACA) 2010. Health care and Education reconciliation act of 2010

Features of PPCA and Health Care Reconciliation Act of 2010

1. SBC (Summary of benefit and coverage) 2. Consumer Assistance Program 3. Appealing Health Plan Decisions 4. Preventive Care

Patient's Bill of Rights

1. Coverage to Americans with Pre-existing Conditions 2. Protects consumers Choice of Doctors 3. Keeps Young Adults Covered 4. Ends Lifetime Limits on Coverage 5. Ends Pre-Existing Condition Exclusions for Children under 19 6. Ends Arbitrary Withdrawals of Insurance Coverage 7. Reviews Premium Increases: 8. Helps Get the Most from Your Premium Dollars 9. Restricts Annual Dollar Limits on Coverage: 10.Removes Insurance Company Barriers to Emergency Services

Demographic Profile (July 2013 est.)

Population: 316,668,567
Sex ratio
at birth: 1.05 male/female 0-14 years: 1.04 male/female 15-24 years: 1.04 male/female 25-54 years: 1 male/female 55-64 years: 0.93 male/female 65 years and over: 0.77 male/female total population: 0.97 male/female

Age structure
0-14 years: 20% (male 32,344,207/ female 31,006,688) 15-24 years: 13.7% (male 22,082,128/ female 21,157,025) 25-54 years: 40.2% (male 63,802,736/ female 63,581,749) 55-64 years: 12.3% (male 18,699,338/ female 20,097,791) 65 years and over: 13.9% (male 19,122,853/female 24,774,052)

Dependency ratios
total dependency ratio: 50.4 % youth dependency ratio: 29.4 % elderly dependency ratio: 21 %

potential support ratio: 4.8 (2013)

Demographic Profile (July 2013 est.)

Population growth rate: 0.9%

Birth rate 13.66 births/1,000 population Death rate 8.39 deaths/1,000 population Total fertility rate 2.06 children born/woman

Demographic Profile (July 2013 est.)

Infant mortality rate total: 5.9 deaths/1,000 live births male: 6.55 deaths/1,000 live births female: 5.22 deaths/1,000 live births Life expectancy at birth total population: 78.62 years male: 76.19 years female: 81.17 years

Demographic Profile (July 2013 est.)

HIV/AIDS - adult prevalence rate -0.6% (2009 est.)

People living with HIV/AIDS -1.2 million (2009 est.)

HIV/AIDS deaths -17,000 (2009 est.)

Oral Health Care

Includes diseases affecting the gums, mouth, and throat (also with cancers of these areas) of people over age 60 lost their natural teeth Top concern of uninsured Americans since 1995 (National Access to Care Survey)

Figure 5 . Untreated Dental Carries by US Population Group in 1999-2002

Mental Disorders

Figure 6 . Percentage of young adults reporting treatment for mental health disorders by demographic characteristics

Figure 7 . Mean Expenditures per person on top 10 most costly conditions among men and women adults age 18 and olde, 2008

Figure 8. Number of people treated for the five most commonly treated conditions, ages 40-64, 2009

References:
Wallace RB, Kohatsu N. editors. Maxcy- Rosenue Last: Public Health and Preventive Medicine. 15th ed. New York; The Mac Graw hill Company: 2008. P1217- 50. Detel R. Holland WW. McEwen J. Ommen J. editors. Oxford Textbook of Public Health. 3rd edition. New York; Oxford University Press. US Department of Health and Human Services, Centre for Disease Control, National Centre for Health Statistics. Health United States 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD. 2012. Chua KP. Overview of American Health System. Available from URL: http://www.amsa.org/AMSA/Libraries/Committee_Docs/HealthCareSystemOv erview.sflb.ashx National Center for Health Statistics, USA. Health, United States, 2011: With special feature on socio-Economic status and health. Hyattsville, MD. 2012. U. S. Department of health and human services. Key Features of law. Available from URL: http://www.healthcare.gov/law/resources/authorities/health-reform-andhhs.html