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  1. Health System in USA VIKASH R 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 2010 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 Care delivery System:

  7. Health Maintenance Organizations (HMOs): • Unique feature of US health system. • 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. • Exposed to significant out-of-pocket costs, including deductibles, copayments, and costs for non-covered services. Part C: • 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 • Effective during 2006.

  17. Table.3: Medicare 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.

  19. Medicaidcont… Optional services: • Rehabilitation care, • Dental care, and • Home and • Community-based long-term care services.

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

  21. Overall Medicaid coverage:

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

  23. 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.

  24. 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.

  25. 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. Source: 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.

  27. Unique feature of US public health system: Council on Linkages between Public Health Practice and Academia: • public health practice “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)

  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) • Long history of Reform in US. • The 2010 health reform basically enactment of 2 laws: Patient protection and Affordable care bill (PPACA) 2010. Health care and Education reconciliation act of 2010 • Key features of these laws are: Pt.’s Rights and Protection: • SBC: Summary of benefit and coverage: • Consumer Assistance Programme: • File complaints and appeals. • Enroll in health coverage • Get educated about your rights and responsibilities.

  30. Key features of 2010 Reforms cont.…… • Appealing Health Plan Decisions • Preventive Care • Patient's Bill of Rights: • Coverage to Americans with Pre-existing Conditions:  • Protects consumer’s Choice of Doctors:  • Keeps Young Adults Covered: • Ends Lifetime Limits on Coverage:  • Ends Pre-Existing Condition Exclusions for Children under 19: • Ends Arbitrary Withdrawals of Insurance Coverage. • Reviews Premium Increases: • Helps Get the Most from Your Premium Dollars:  • Restricts Annual Dollar Limits on Coverage: • Removes Insurance Company Barriers to Emergency Services:

  31. Key features cont.…. • Doctor Choice & ER Access: • Grandfathered Health Plans Insurance Choices: • Pre- Existing condition insurance plan (PCIP): • Young Adult Coverage: • Affordable insurance exchange: • CO – OP insurance plans: • Preventive and other services for > 65 years under Medicare and also covers donut hole. • Medicare Drug Discounts: to cover the donut hole

  32. Health System: US ---- INDIA • Multiple players. • Different Providers. • Private Pre- dominance. • Private Insurance • Private service providers

  33. 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. Holland WW. McEwen J. Ommen J. editors. Oxford Textbook of Public Health. 3rd 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: http://www.amsa.org/AMSA/Libraries/Committee_Docs/HealthCareSystemOverview.sflb.ashx • National Center for Health Statistics, USA. Health, United States, 2011: With special feature on socio-Economic status and health. Hyattsville, MD. 2012. • U. S. Department of health and human services. Key Features of law. Available from URL: http://www.healthcare.gov/law/resources/authorities/health-reform-and-hhs.html

  34. THANKS THANKS