Module 5: Healthcare Systems US Healthcare Delivery Systems

Module 5: Healthcare Systems US Healthcare Delivery Systems Developed through the APTR Initiative to Enhance Prevention and Population Health Education in collaboration with the Brody School of Medicine at East Carolina University with funding from the Centers for Disease Control and Prevention

Acknowledgments APTR wishes to acknowledge the following individuals that developed this module: Joseph Nicholas, MD, MPH University of Rochester School of Medicine Anna Zendell, PhD, MSW Center for Public Health Continuing Education University at Albany School of Public Health Mary Applegate, MD, MPH University at Albany School of Public Health Cheryl Reeves, MS, MLS Center for Public Health Continuing Education University at Albany School of Public Health This education module is made possible through the Centers for Disease Control and Prevention (CDC) and the Association for Prevention Teaching and Research (APTR) Cooperative Agreement, No. 5U50CD300860. The module represents the opinions of the author(s) and does not necessarily represent the views of the Centers for Disease Control and Prevention or the Association for Prevention Teaching and Research.

Presentation Objectives 1. 2. 3. 4. 5. List the major sectors of the US healthcare system Describe interactions among elements of the healthcare system, including clinical practice and public health Describe the organization of the public health system at the federal, state, and local levels Describe the impact of the healthcare system on special populations Describe roles and interests of oversight entities on US health system policy

System Overview Consumers Obtain health care Healthcare Professionals Diagnose Treat Care Facilitating Organizations Finance Coordinate Regulate

Goals of Healthcare Delivery System Quality Access Cost (Often) competing goals

Questions to Consider Who currently utilizes health care in the US? Where do most healthcare encounters occur? What is the reason for most encounters? What are the different models for organizing, funding and regulating these encounters? How do public health and clinical practice influence one another?

System Demands 1.2 billion ambulatory visits per year (2008) Children - routine health check and respiratory infections Young women - pregnancy, gynecologic care Adults (both sexes) - hypertension, ischemic heart disease, and diabetes mellitus 35 million hospital discharges (2006) Average length of stay - 4.8 days 46 million procedures performed National Center for Health Statistics 2008

Overview of Public Health System

Role of Public Health Federal Regulation of commerce Control entry of persons to US Control inspection/entry of products to US and across state lines Funding of public health programs Provision of care for special populations Coordination of federal agencies

Role of Public Health State Community health assessment Public health policy development Assurance of public health service provision to communities Continuity between federal public and local public health Conduit for funding Linkage of resources to needs

Role of Public Health Local May be city and/or county-based Provide mandated public health services Enact and enforce public health codes as mandated by state and federal officials Must meet minimum threshold of state standards May be more rigorous than state standards

Local Public Health Functions Vital statistics Communicable disease control Maternal and child health Environmental health Health education Public health laboratories

Clinical Medicine and Public Health Clinical Medicine Patient-focused Diagnosis and treatment Medical care paradigm Public Health Population-focused Disease prevention and health promotion Spectrum of interventions

Healthcare System Sectors

Types and Settings of Services Types of Healthcare Services Delivery Settings Preventive Care Public Health Programs Community Programs Personal Lifestyles Primary Care Physician Office/Clinic Self-Care Alternative Medicine Specialized Care Specialist Clinics Chronic Care Primary Care Settings Specialist Provider Clinics Home Health Long-term Care Facilities Self-Care Alternative Medicine Shi & Singh 2008

Types and Settings of Services (2) Types of Healthcare Services Delivery Settings Long-term Care Long-term Care Facilities Home Health Special Sub-Acute Units (Hospital, Long-term Care Facilities) Home Health Outpatient Surgical Centers Hospitals Rehabilitation Departments (Hospital, LongTerm Care Facilities) Home Health Outpatient Rehabilitation Centers Hospice Services Sub-Acute Care Acute Care Rehabilitative Care End-of-Life Care Shi & Singh 2008

Primary Care Typically address acute, chronic, preventive/wellness issues Coordinate specialty care when needed Providers are typically generalists (MD/DO/NP/PA) Primary care specialties : Family Medicine, General Internal Medicine, Pediatrics, Obstetrics-Gynecology Develop ongoing patient-provider relationship Multiple settings: provider offices, clinics, schools, colleges, prisons, worksites, home, mobile vans

Secondary Care Typically subspecialty care focused on a particular organ system or disease process Available in most communities Includes common inpatient and outpatient services Subspecialty office care Inpatient care including emergency care, labor and delivery, intensive care, diagnostic imaging

Tertiary Care Consultative subspecialty care Typically provided at large regional medical centers Characterized by advanced technology and high volume of procedures Tertiary care sites usually serve as major education sites for students in a variety of health professions

Prevention Triangles Tertiary Medical Care Tertiary Prevention Secondary Prevention Secondary Medical Care Relative Investment Primary Medical Care Clinical Preventive Services Primary Prevention Population Oriented Prevention 2% of

Current System Components Personnel Healthcare institutions US Public Health Service Commissioned Corps Drug and device manufacturers Education and research

Personnel Nurses Physicians (MD/DO) NP,PA, midwives Pharmacists Dentists Several million ancillary personnel 80% involved in direct healthcare provision Therapists, social workers, lab technicians National Center for Health Statistics 2004

Personnel Provider Practice Organizations Traditional solo practitioner model is fading Most providers join larger groups Private, physician-owned groups Health system owned groups (networks) Health maintenance organizations Preferred provider organizations

Healthcare Institutions Hospitals Private, community hospitals Not for profits are most common Many are religiously affiliated Private, for profit Public (state or local government) Psychiatric hospitals Academic medical centers VA and military centers

Other Major Healthcare Institutions Long term care facilities Nursing homes/skilled nursing facilities Assisted living facilities* Enhanced care facilities* Adult homes* Rehabilitation facilities Physical rehabilitation Substance abuse facilities *These residential long-term care facilities are not really healthcare institutions but commonly referred to as such.

US Public Health Service Commissioned Corps 6,600 full time clinical and public health professionals Provide primary care in underserved areas Staff domestic and international public health emergencies Work in research, administrative and public health capacities in a number of federal agencies

Pharmaceuticals and Devices Large industry with major impact on cost and policy 234 billion in 2008 Growing rapidly with the passage of Medicare D (prescription benefit) Regulated by Food and Drug Administration Hartman et al 2010

Education and Research Public/Private funding mix supports undergraduate nursing, medical and physician assistant programs Public funding of Graduate Medical Education US does not actively manage specialty choice or distribution of its physician workforce Government is major funder for basic medical research Industry is major funder for clinical trials of drugs, and devices and continuing medical education

Healthcare Oversight

Healthcare Regulation Web Diverse set of regulators Government (state, federal, local) Insurers Hospitals Private accrediting bodies Professional societies

Goals of Healthcare Delivery System Access Quality Cost (Often) competing goals

State Regulation Most healthcare regulation comes from states Licensure and oversight of medical facilities and providers Control distribution of services through certificate of need process Regulate insurance coverage Mandate minimum standards Regulate cost, scope of coverage and exclusion criteria

Certificate of Need (CON) Purpose Cost containment Prevent unnecessary duplication of health care Ensure high quality health services Accomplishes this through many roles Extensive review process

Federal Regulation Regulatory power derived from federal status as the major payor in most systems (Medicare, Medicaid) Reimbursement is increasingly tied to compliance with federal standards Department of Health and Human Services (DHHS) is the major federal actor in healthcare regulation

Major Federal Healthcare System Regulatory Agencies DOD DHHS CMS CDC SAMHS A HRSA VA IHS FDA

Regulators Insurers Contract with physicians/hospitals to encourage Quality Cost control Market share Set standards Audit providers and institutions Adjust payments accordingly

Regulators Hospitals Credential physicians, physician assistants, midwives, nurses, other healthcare staff Hospital credentialing often necessary for malpractice insurance eligibility Regular review of medical staff for quality, professional conduct and practice standards

Regulators Private Accrediting Organizations JCAHO (Joint Commission on Accreditation of Healthcare Organizations) Accredits hospitals Private organization of member hospitals NCQA (National Committee for Quality Assurance) Accredits managed care plans Private organization representing employers/purchasers Specialty Organizations Specific certifications (bariatric surgery centers, Baby Friendly USA)

Professional Societies Historically the major regulator of healthcare delivery until increasing influence of government and insurance industries Still influential in determining acceptable professional practice standards, and contributing to regulatory policy

Professional Impairment Regulatory System Response Most common impairments Substance abuse/dependency Mental illness Aging-related impairments a growing problem Trend toward treatment vs. sanction

Special Populations

Veterans Unique health care infrastructure Inter-generational health care needs Health/public health considerations War-related injuries Chemical exposure Homelessness Post traumatic stress disorder Prisoners of war

Indian Health Service Created through treaties between US government and Indian tribes Eligibility for US benefits and programs Contract Health Services (CHS) to supplement Considerations for American Indians Safe water and sewage Injury mortality rate 2-4x other Americans

Students K-12 Student Health Centers Medical, psychosocial, preventive care for all Age appropriate health education College Student Health Center Medical and preventive care for all Campus health emergencies

Correctional Facilities Privatization and telemedicine are growing trends to meet prisoner healthcare needs Unique considerations Injuries, infectious diseases, and substance abuse very prevalent 50% of inmates suspected to have mental illness Aging in prisons Must address barriers to health care – secure escort

Intellectual/Developmental Disabilities Considerations Intellectual/Developmental Disabilities (I/DD)specific clinic or integrated health care Consent capacity Surrogate Decision Making Committees Guardianship Diagnostic, treatment challenges Caregiver perspectives on health concerns

Global Perspective on Healthcare Systems

Evaluation of US Healthcare System Strengths Advanced diagnostic and therapeutic technology Timely availability of subspecialists and procedures

Evaluation of US Healthcare System Weaknesses Limited access to multiple underserved populations High cost with marginal population outcomes Fragmentation of care Insufficient primary care workforce Highly bureaucratic/large administrative costs Misaligned incentives

Healthcare System Models Socialized Medicine (United Kingdom Model) Government is dominant service payor and provider Fund through taxes Universal access In US, this is model for Veterans Affairs (VA) Socialized Insurance (Bismark Model) Private insurance is dominant payor Fund via employers and/or employees Need additional mechanisms for universal access In US, this is primary model for citizens 65 years

Healthcare System Models National Health Insurance (Canadian Model) Government is dominant payor Providers, hospitals are a mix of public/private Funded through taxes Universal access In US, this is the model for Medicare and Medicaid Out of Pocket Model No organized system for payment No pooling of risk Access limited In US, this is the model faced by large numbers of uninsured

Systems Comparisons

Outcomes - Life Expectancy

Current Trends Medical Tourism Concierge Medicine Physician retainer fee Executive healthcare

Current Trends - Attempts to Expand Access Insurance/Payment reforms Less exclusion, access to larger pools Offering less comprehensive benefits/limiting choice Shifting more costs to consumers High deductible plans Health savings accounts Subsidize private insurance Medicaid eligibility expansion Funding of community health centers

Federally Qualified Health Centers Provide primary health care access to persons regardless of ability to pay Includes mental health, dental, transportation, translation, education Accept insurance Grant funded by HRSA, enhanced payments from Medicare/Medicaid Types Community health centers Migrant health centers Healthcare for the Homeless Programs Public Housing Primary Care Programs

System at the Brink? Accelerating healthcare costs promise to swamp access/quality issues Workforce and hospitals are geared to provide expensive, high-tech, tertiary care for the foreseeable future Aging population living longer with more comorbidities

Impending Demographic Tsunami

Paradigm Shift in Healthcare Delivery Trends and Directions in Healthcare Delivery Illness Acute Care Inpatient Individual Health Fragmented Care Independent Institutions Service Duplication Wellness Primary Care Outpatient Community Well-Being Managed Care Integrated Settings Continuum of Services

Summary US healthcare system is a large patchwork of public and private programs Public funds account for nearly 50% of healthcare spending Cost is rapidly becoming dominant policy issue Quality and access remain significant policy issues

Collaborating Institutions Department of Public Health Brody School of Medicine at East Carolina University Department of Community & Family Medicine Duke University School of Medicine

Advisory Committee Mike Barry, CAE Lorrie Basnight, MD Nancy Bennett, MD, MS Ruth Gaare Bernheim, JD, MPH Amber Berrian, MPH James Cawley, MPH, PA-C Jack Dillenberg, DDS, MPH Kristine Gebbie, RN, DrPH Asim Jani, MD, MPH, FACP Denise Koo, MD, MPH Suzanne Lazorick, MD, MPH Rika Maeshiro, MD, MPH Dan Mareck, MD Steve McCurdy, MD, MPH Susan M. Meyer, PhD Sallie Rixey, MD, MEd Nawraz Shawir, MBBS

APTR Sharon Hull, MD, MPH President Allison L. Lewis Executive Director O. Kent Nordvig, MEd Project Representative