Health System in USA

1. Health System in USA VIKASH RANJAN KESHRI Moderator: Dr. P. R. Deshmukh

2. Outline of Presentation: • Introduction • Organizational structure • Health Care Delivery System in US • Components of US health System • Major Stakeholders in the Health Care System in US • Health Financing: • Private Health Insurance • Government Health Insurance: Medicare Medicaid SCHIP • Public Health System • Health Care Reform in USA

3. Introduction: • Complexity of Health System in USA • Relies on a combination of governmental action, market forces, and voluntary charitable initiatives to deliver health services.

4. Organizational Structure:

5. Health care delivery system in USA: • The health care delivery system in USA is in piecemeal. • Overall the system goes like this:

6. Components of US Health System:

7. Health Maintenance Organizations (HMOs): • These are unique feature of US health system. These organizations are within the private system in US only. • Staff Model: Physicians work for HMOs. • Group Model: HMO contract with separate physicians group to provide its service. • Pre- paid group practice (PPGP). • IPA: Individual Practice Association.

8. Major Stakeholders:

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

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

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

12. Health-Care Purchasers:

13. Flow Chart: over view of health financing

14. Medicare: Three basic categories of beneficiaries: • Individuals age 65 and older, • Individuals who are permanently and completely disabled, and • Individuals with end-stage renal disease. Four major components: PART - A PART - B PART - C PART - D

15. PART- A Coverage: Coverage under part- A is 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: financed by employer and employee payroll tax. • Out of pocket deductible for hospital care. • Fixed amount for an episode of care.

16. PART - B • Covers physician care and other outpatient services. • Optional benefit • Beneficiaries are responsible for paying a monthly premium. • beneficiaries exposed to significant out-of-pocket costs, including deductibles, copayments, and costs for non-covered services. Part C: • Component of the Medicare program, covers an array of managed care plans an alternative to the traditional Medicare program. • Medicare +Choice program. Part – D: • Coverage for outpatient prescription drugs. • As part of the Medicare Modernization Act of 2003 and • Took effect during 2006.

17. Table.3: Medicare and Medicaid coverage for age 65 yrs. and above.

18. Medicaid: • Single largest health-care program in the country. • Jointly financed and administered by the federal government and individual state governments. • Beneficiary: Poor, Elderly, Disabled, Children, Pregnant Women and Parents of young children 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 include: • rehabilitation care, • dental care, and • home and • community-based long-term care services.

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

20. Overall Medicaid coverage:

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

22. SCHIP:State Children’s Health Insurance Program • Started in 1997. • For low-income children not eligible for the traditional Medicaid program. • uninsured children who reside in families with incomes below 200% of the FPL or whose family has an income 50% higher than the state’s Medicaid eligibility threshold. • Jointly financed and administered by the federal government and individual state governments. Veteran’s Administrations: • Federally administered program for veterans of the military. • Health care is delivered in government-owned VA hospitals and clinics.

23. 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.

24. USA: Public Health System: Public Health’s Three Core Functions: (as defined by IOM) • Assurance • Policy Development • Assessment The Ten Essential Services: • Based on the three core principles, ten essential services has been defined:

26. Unique feature of US public health system: • Council on Linkages between Public Health Practice and Academia: • public health practice is “de-coupled” from its academic base • to facilitate additional activities that would enhance the practice/academic connection • Organizations under the Public Health System: • The current operational arms of the PHS include: • 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 and Disease Registry (ATSDR) (administered by the CDC), and Substance Abuse and Mental Health Administration (SAMHA)

27. The Ten Essential Services: • The three core functions were further expanded to a list of Ten Essential Community Health Services that would more clearly define the services communities need in order to achieve high levels of healthfulness.6 Those Ten Essential Services are: • Monitor health status to identify community health problems. • Diagnose and investigate health problems and health hazards in the community. • Inform, educate, and empower people about health issues. • Mobilize community partnerships to identify and solve health problems. • Develop policies and plans that support individual and community health efforts. • Enforce laws and regulations that protect health and ensure safety. • Link people to needed personal health services and ensure the provision of health care when otherwise unavailable. • Ensure a competent public health and personal health workforce. • Evaluate effectiveness, accessibility, and quality of personal and population-based health services. • Research for new insights and innovative solutions to health problems.

28. 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.

29. Health Care Reform: 2010 (Obama Care) ????????????????????????????????????

30. 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. McEwen J. Beaglehole R. Tanaka H. editors. Oxford Textbook of Public Health. 2nd 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: