Ch 1 - Major Characteristics of U.S. Health Care Delivery Flashcards
Managed Care
Seeks to achieve efficiency by integrating the basic functions of health care delivery
Employs mechanisms to control (manage) utilization of medical services
Determines the price at which the services are purchased and how much the providers get paid
Is the most dominant health care delivery system in the United States and available to most Americans
Employers and government are the primary financiers of managed care.
An MCO functions like an insurance company: It promises to provide health care services contracted under the health plan to the enrollees of the plan.
Military
Available free of charge to:
Active duty military personnel of the U.S. Army, Navy, Air Force, and Coast Guard
Certain uniformed nonmilitary services such as the Public Health Services and NOAA
The military medical care system: Is well-organized Is highly integrated Is comprehensive Covers preventative care
Special (Vulnerable) Population
Particularly the poor, uninsured, minorities, and immigrants living in disadvantaged communities and receiving care from “safety net” providers
Safety nets are not secure.
Provider type and availability vary.
Some individuals forgo care and seek hospital emergency services if nearby.
Providers are pressured to see an increased number of uninsured individuals.
Medicaid, the primary financial source for the safety net, does not allow much cost shifting.
Integrated Delivery System
A network of organizations that provides or arranges to provide a coordinated continuum of services to defined populations held clinically and fiscally accountable for outcomes and health status
The hallmark of the U.S. health care industry: to form integrated delivery systems (IDS)
Have various forms of ownership and links among hospitals, physicians, and insurers
IDS’s objective is:
To have one health care organization deliver a range of services for a defined population
Long-Term care Delivery
Consists of medical and nonmedical care that is provided to individuals who are chronically ill or who have a disability
By 2020, more than 12 million Americans are projected to require long-term care
Public Health System
Monitoring health status to identify and solve community health problems
Diagnosing and investigating health problems and hazards
Informing and educating people about health problems and hazards
Mobilizing the community to solve health problems
Developing policies to support individual and community health efforts
Enforcing laws and regulations to support health safety
Providing people with access to necessary care
Ensuring a competent and professional health workforce
Evaluating the effectiveness, accessibility, and quality of personal and
population-based health services
Performing research to discover innovative solutions to health problems
Health Care/Services Delivery
Refers to the:
- Major components of the system
- Processes that enable people to receive health care
- Provision of health care services to patients
Enrollee
A member
An individual covered under the plan
Health Plan
Is a contractual arrangement between the MCO and the enrollee
Includes a list of covered health services to which enrollees are entitled
Uses selected providers, usually primary care, general practitioners (the “gatekeepers”)
Tricare
Financed by the military and covers families, dependents, or retired military
The VA Health Care System
Is available to retired veterans
Focuses on hospital, mental health, and long-term care
Is one of the largest and oldest (1946) organized health systems in the world
The mission of the VA health care system is to provide medical care, education and training, research, contingency support, and emergency management for the Department of Defense medical care system.
Budgets over $40 billion
Employs over 280,000
Veterans Integrated Service Networks (VISN)
The VA is organized into 23 geographically distributed Veterans Integrated Service Networks (VISN).
Each VISN:
Coordinates its own services
Receives federal funds
Key Characteristics of the U.S. Health Care System
No central governing agency; little integration and coordination
Technology-driven and focuses on acute care
High on cost, unequal in access, and average in outcomes
Imperfect market conditions
Government as subsidiary to the private sector
Market justice vs. social justice
Multiple players and balance of power
Quest for integration and accountability
Access to health care selectively based on insurance
Legal risk influences practice behavior.
Access
Is restricted in the United States to those who:
Have health insurance through an employer
Are covered under a government program
Can afford to buy insurance out of pocket
Are able to pay for services privately
Key System Players
Physicians
Administrators of health care institutions
Insurance companies
Large employers
Government
