Chapter 13: Health Care Delivery In The United States

Chapter 13 health Care Delivery In The United Stateschapter Objectives

Define the term healthcare system. Trace the history of healthcare delivery in the United States from colonial times to the present. Discuss and explain the concept of the spectrum of healthcare delivery. Distinguish between the different kinds of health care, including population-based public health practice, medical practice, long-term practice, and end-of-life practice. List and describe the different levels of medical practice.

List and characterize the various groups of healthcare providers. Explain the differences among allopathic, osteopathic, and nonallopathic providers. Define complementary and alternative medicine. Explain why there is a need for healthcare providers. Prepare a list of the different types of facilities in which health care is delivered.

Explain the differences among private, public, and voluntary hospitals. Explain the difference between inpatient and outpatient care facilities. Briefly discuss the options for long-term care. Explain what the Joint Commission does. Identify the major concerns with the healthcare system in the United States.

Explain the various means of reimbursing healthcare providers. Briefly describe the purpose and concept of insurance. Define the term insurance policy. Explain the insurance policy terms deductible, co-insurance, copayment, fixed indemnity, exclusion, and pre-existing condition. Explain what is meant when a company or business is said to be self-insured.

List the different types of medical care usually covered in a health insurance policy. Briefly describe Medicare, Medicaid, and Medigap insurance. Briefly describe the Children’s Health Insurance Program (CHIP). Briefly explain long-term care health insurance. Define managed care.

Define the terms health maintenance organization (HMO), preferred provider organization (PPO), and point-of-service option. Identify the advantages and disadvantages of managed care. Define consumer-directed health plans and give several examples. Provide a brief overview of the Affordable Care Act passed in 2010. Summarize the three cases that have been heard by the U.S. Supreme Court that have had an impact on the Affordable Care Act.

Healthcare delivery in U.S. is unlike other developed countries. Delivered by an array of providers in a variety of settings. Paid for in a variety of ways. Is U.S. health care a “system”?

History of Healthcare Delivery in the U.S. (1 of 2): Self-care has been a category of health care throughout history and today. From colonial times through late 1800s, anyone trained or untrained could practice medicine. Past medical education was not as rigorous as today. Early medical education was experience-based only, prior to 1870.

History of Healthcare Delivery in the U.S. (2 of 2): Most care was provided in patients’ homes. Hospitals only in large cities and seaports. Functioned more in a social welfare manner. Not clean; unhygienic practice. Almshouses, pesthouses.

Healthcare Delivery in the Late 1800s – Early 1900s (1 of 2): Care moved from patient’s home to physician’s office and hospital. Building and staffing improved; designed for patient care; trained personnel; medical supplies. Reduced travel time. Science played a bigger role in medical education. Mortality declined due to public health measures.

Healthcare Delivery in the Late 1800s – Early 1900s (2 of 2): By early 1920s, chronic diseases replaced communicable diseases as leading causes of death. New procedures: X-ray, specialized surgery, chemotherapy, ECG. Doctors and nurses became more specialized. In 1929, healthcare was 3.9% of GDP. Patients paid bills, set prices based on ability to pay.

Healthcare Delivery – 1940s and 1950s: WWII impacted healthcare delivery. Wage restrictions led employers to use health insurance to attract workers. Major advances in technology and facilities increased costs. Hill-Burton Act improved infrastructure. Healthcare began to be seen as a basic right versus privilege.

Healthcare Delivery – 1960s: Shortages and maldistribution of care increased interest in insurance. Third-party payment systems became standard. In 1965, Medicare and Medicaid were established.

Healthcare Delivery – 1970s: Health Maintenance Organization Act of 1973; Organizational efforts to contain costs and prevent unnecessary facilities, procedures.

Healthcare Delivery – 1980s: Deregulation, competition, proliferation of medical technology, elaborate insurance programs. Questionable value in cost reduction.

Healthcare Delivery – 1990s: American Health Security Act (1993), managed care to improve efficiency, control costs, and utilization. Healthcare spending continued to rise. CHIP was introduced. The 2003 Medicare Prescription Drug, Improvement, and Modernization Act expanded coverage.

Healthcare in the 21st Century: The World Health Report 2000 ranked U.S. healthcare 37th out of 191 countries. The 2009 Reauthorization of CHIP and the 2010 Affordable Care Act (ACA) aimed to expand coverage, improve quality and reduce costs. Several Supreme Court cases have challenged components of the ACA.

Introduction: Healthcare in the U.S. is delivered by a complex system of providers and settings, paid for through multiple mechanisms. Compared globally, the U.S. has a unique, costly, and fragmented healthcare system, often debated for its efficiency, accessibility, and quality.

Spectrum of Healthcare Delivery: Encompasses population-based public health, medical practice, long-term care, and end-of-life services. Public health efforts focus on prevention and health promotion, often through government agencies. Medical practice ranges from primary care to highly specialized tertiary care, with additional services in long-term and end-of-life care settings.

Healthcare Providers: Over 12 million workers across diverse roles including physicians, nurses, allied health professionals, and public health workers. Providers include allopathic (MD), osteopathic (DO), nonallopathic (chiropractors, acupuncturists), and limited care providers like dentists, optometrists, podiatrists.

Facilities and Accreditation: Healthcare services are provided in inpatient and outpatient facilities. Hospitals vary by ownership (private, public, voluntary), with outpatient services including clinics, urgent care, retail clinics, and specialized centers. Accreditation by organizations like The Joint Commission ensures quality standards are met.

Structure and Functions of the U.S. Healthcare System: The system's complexity involves stakeholders, policies, and politics. Major issues include cost containment, access, and quality. The Affordable Care Act aimed to extend coverage, improve affordability, and enhance quality, though challenges persist.

Access to Care & Quality: Insurance coverage significantly influences access. The uninsured rate has declined but remains impacted by cost and socioeconomic factors. Quality measures include effectiveness, safety, timeliness, patient-centeredness, equity, and efficiency, monitored via agencies like AHRQ and NCQA.

Cost and Payment Systems: U.S. healthcare expenditures surpassed $3 trillion in 2014. Payment methods include fee-for-service, bundled payments, capitation, and value-based programs like pay-for-performance. Insurance acts as risk-sharing, equitable but potentially costly, with policies containing premiums, deductibles, co-insurance, and exclusions.

Government Insurance Programs: Medicare covers those >65 years and certain disabilities, funded by payroll taxes, with Parts A-D. Medicaid targets low-income populations, state-administered with federal matching. CHIP provides coverage for eligible children. Long-term care insurance and supplemental policies like Medigap help manage out-of-pocket costs.

Managed Care: Encompasses HMOs, PPOs, POS, and other arrangements to control costs through provider networks, gatekeeping, and risk-sharing. Managed care aims at efficiency but can limit choice and flexibility.

Healthcare Reform and Policy: The ACA introduced consumer-directed health plans, health savings accounts, and extensive reforms to improve coverage, prevent abuses, and standardize quality. Ongoing legal challenges to the ACA's provisions continue to influence policy implementation.

Paper For Above instruction

The delivery of healthcare in the United States is a highly complex and multifaceted system that differs significantly from healthcare systems in other developed nations. It encompasses a wide array of healthcare providers, settings, and payment mechanisms, resulting in a system that is often described as fragmented and expensive. Understanding the evolution of this system, its current structure, and ongoing reforms is essential to comprehend its strengths, weaknesses, and future directions.

Historically, healthcare delivery in the U.S. has evolved from informal self-care and community-based acts in colonial times to a structured system involving hospitals, clinics, and specialized providers. Initially, medical practice was often unregulated, with practitioners of varying training and expertise providing care within patients’ homes. Hospitals appeared primarily in urban centers, serving social welfare roles, often unhygienic and underfunded. Significant progress came in the late 19th and early 20th centuries with advances in medical science, education, and public health measures that reduced mortality rates. During these periods, the medical profession became more specialized, and public health initiatives contributed to declining infectious disease rates.

The mid-20th century marked a turning point with the introduction of health insurance, especially during WWII when wage restrictions heightened employer-based insurance as a recruitment tool. The establishment of Medicare and Medicaid in 1965 expanded coverage to vulnerable populations, drastically changing the healthcare landscape. The subsequent decades saw efforts to control costs through legislation such as the Health Maintenance Organization Act of 1973 and plans for cost containment, which faced challenges including technological proliferation and market-driven reforms. The 1980s and 1990s witnessed deregulation and managed care expansion, with considerable debate about their efficiency and impact on quality.

The 21st century has intensified focus on healthcare reform, exemplified by the Affordable Care Act of 2010, which aimed to extend coverage, improve quality, and control costs. Despite these efforts, the system continues to face critical issues such as high costs, disparities in access, and varying quality of care. The U.S. system is characterized by a spectrum of care, including population health initiatives, primary and specialized medical services, long-term and end-of-life care, delivered across diverse settings—hospitals, outpatient clinics, nursing homes, and home health services.

Providers in the U.S. include physicians (MDs and DOs), nurses, allied health professionals, and public health workers. They operate within a layered system of facilities that vary by ownership, purpose, and accreditation status. Hospitals are classified as private, public, or voluntary and must meet standards set by organizations like The Joint Commission. Outpatient services encompass clinics, urgent care, and retail health centers, offering accessible and cost-effective care. Long-term care services include nursing homes, home health, and community-based programs designed to support individuals with chronic illnesses, disabilities, or recovering from illness.

Payment for healthcare services involves multiple mechanisms, including out-of-pocket expenses, private insurance, government programs, and employer-based plans. Insurance policies contain various terms such as premiums, deductibles, co-insurance, and exclusions, reflecting the costs and risks shared among insured parties. Public programs like Medicare and Medicaid serve specific populations—elderly, disabled, low-income—while CHIP addresses pediatric health needs. Managed care models like HMOs, PPOs, and POS attempt to balance cost control with access and quality by regulating networks and utilization.

Reform efforts continue amidst challenges posed by legal disputes, rising costs, and disparities. The implementation of consumer-directed health plans, health savings accounts, and other provisions seeks to empower consumers and contain costs. Yet, ongoing debates question whether these reforms have adequately addressed systemic issues such as inequity, affordability, and quality, necessitating continued policy innovation and evaluation.

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