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

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health system in usa

Health System in USA

VIKASH R KESHRI

Moderator

Dr. P. R. Deshmukh

outline of presentation
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
introduction
Introduction:
  • Complexity of Health System in USA
  • Relies on a combination of governmental action, market forces, and voluntary charitable initiatives to deliver health services.
health care d elivery system in usa
Health Care Delivery System in USA:
  • The health care delivery system in USA is in piecemeal.
  • Overall the system goes like this:
h ealth maintenance organizations hmos
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.
health care workforce
Health Care Workforce:

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

medicare
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

part a
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.
part b
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.
medicaid
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.
medicaid cont
Medicaidcont…

Optional services:

  • Rehabilitation care,
  • Dental care, and
  • Home and
  • Community-based long-term care services.
schip state children s health insurance program
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.
private health insurance
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.
usa public health system
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:
slide26

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.
unique feature of us public health system
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)
the state public health role
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.
health care reform 2010 obama care
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.
key features of 2010 reforms cont
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:
key features cont
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
health system us india
Health System: US ---- INDIA
  • Multiple players.
  • Different Providers.
  • Private Pre- dominance.
  • Private Insurance
  • Private service providers
references
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
slide34

THANKS

THANKS