The US Healthcare System and the Roemer Model

1. The US Healthcare Systemand the Roemer Model Lecture 2 Tracey Lynn Koehlmoos, PhD, MHA HSCI 609 Comparative International Health Systems

2. Organization of the US Health Services System • Ever shifting mix of public/government sector, private sector and voluntary services. • 16% of GDP spent on health services (2005) • The US government now: • Major payer for care: Medicare, Medicaid • Provider of healthcare for special populations like Tricare, Indian Health Services, VA • Major supporter of education and training of many types of care providers

3. Introduction to the Roemer Model • Developed by Milton I. Roemer, MD, MPH • WHO, UCLA School of Public Health • Pioneer in international health systems research • Roemer Model of Health Services System (1984) allows for clear understanding of health systems Clear understanding = Meaningful comparisons

4. MANAGEMENT RESOURCE PRODUCTION ORGANIZATION OF PROGRAMS DELIVERY OF SERVICES ECONOMIC SUPPORT Roemer Model

5. Five Parts to the Model • Organization of the Program • Management of Health Services System • Economic Support of Health Services • Production of Health Services Resources • Delivery of Health Services

6. Part 1: Organization • Ministry of Health—all levels • Other Public Agencies • Voluntary Agencies • Enterprises • Private Market

7. Part 2: Management • Planning • Administration • Regulation • Legislation

8. Part 3: Economic Support • Personal Households • Charity • Insurance (voluntary) • Social Security • Governmental • Revenues • Foreign Aid

9. Part 4: Production of Resources • Manpower • Facilities • Commodities (drugs, DME, equipment, etc.) • Knowledge

10. Part 5: Delivery of Services • Primary Care—Prevention • Primary Care—Treatment • Secondary Medical Care • Tertiary Medical Care • Care of Special Disorders and Populations

11. Applying Roemer at Home • Part I: Organization of Health Services: • US health system is DECENTRALIZED • Department of Health and Human Services (DHHS) instead of MoH • DHHS regulates and finances many health services • Services delivery primarily occurs in private sector

12. Part I: Organization • Public Health at the national level • Centers for Disease Control and Prevention • Food and Drug Administration • Centers for Medicare and Medicaid • National Institutes of Health • Agency for Healthcare Research and Quality

13. Part I: Organization • Voluntary Agencies • Gap fillers • Disease or interest group specific ACS, ARC, AARP • Professional associations APHA, AHA, AMA • Philanthropic and religious organizations Robert Wood Johnson

14. Part I: Organization • Private Market • Most health services provided in the private market • Most health insurance provided in the private market • Pharmaceuticals and supplies (developed and sold) • Health professional training

15. Part 2: Management • Planning: No centralized national-level planning authority • Administration: More applied in nature at project or program level • Legislation: all government units have authority to enact laws (budgeting process, restriction and limitations, new programs • Regulation: Implementation of laws, licensure, certification, accreditation

16. Part 3: Economic Support • Private Health Insurance (voluntary and employment related) largest source of funds (34%) to US health services • ~70% of <65 have some type of health insurance • Household/Out of Pocket: 15% • Medicare: 17% • Medicaid: 16% • $1.3 trillion in 2000 • 16% of GDP in 2005

17. Part 3: Economic Support • Where does the money go? • 33% hospitals (50% of this from Fed.) • 23% physician services • 10% drugs • 9% other personal care • 7% nursing homes • 6% program administration • 3% research and construction • 2% home health care

18. Part 4: Production of Resources • Manpower: Health Services Industry • Largest Industry in US: 11.9 million workers • 800,000+ physicians • 270.6 per 100,000 population • 2:1 Specialist to Generalist practitioners • Medicare subsidized training (GME/residencies) • 2 million+ nurses: shortage, training variations • Pharmacists, dentists, RT, OT, PT • Health Administrators

19. Part 4: Production of Resources • Hospitals: • Various categories (I, II, III) & structures • Merge and integrate to expand scope • Financial challenges, cost shifting • Prospective Payment, negotiated rates • Biomedical Research and Technology: • US most advanced on planet/ cost driver • Drugs developed in private sector/FDA approval • Most research publicly funded (via NIH) • No clear chain of dissemination/assessment

20. Part 5: Delivery Systems Continuum of Care • Prevention and Promotion: Public Sector • Early Detection: Public and Private • Primary Care: Private sector; PCP • Secondary Care: Specialists/hospitals • Tertiary Care: Academic Health Center • Long Term Care: Medicaid is big payer • Palliative Care: Home or Hospice Medicare $ for 80% • Outside the continuum: chronic mental illness

21. MANAGEMENT RESOURCE PRODUCTION ORGANIZATION OF PROGRAMS DELIVERY OF SERVICES ECONOMIC SUPPORT Roemer Model

22. Conclusion • Applying the Roemer Model to the US Healthcare System gives us a means to understand the system and make meaningful and direct comparisons. • Skyrocketing costs, an aging population & a high percent of uninsured are issues of concern • Quality-Access-Cost remain the overarching values of concern for the US healthcare system