The US Healthcare System and the Roemer Model Lecture 2 Tracey Lynn Koehlmoos, PhD, MHA HSCI 609 Comparative International Health Systems

Organization of the US Health Services System Ever shifting mix of public/government sector, private sector and voluntary services. 16% of GDP spent on health services (2005) The US government now: Major payer for care: Medicare, Medicaid Provider of healthcare for special populations like Tricare, Indian Health Services, VA Major supporter of education and training of many types of care providers

Introduction to the Roemer Model Developed by Milton I. Roemer, MD, MPH WHO, UCLA School of Public Health Pioneer in international health systems research Roemer Model of Health Services System (1984) allows for clear understanding of health systems Clear understanding = Meaningful comparisons

Roemer Model MANAGEMENT ORGANIZATION OF DELIVERY RESOURCE OF SERVICES ORGANIZATION OF PROGRAMS MANAGEMENT ECONOMIC SUPPORT RESOURCE PRODUCTION

Five Parts to the Model Organization of the Program Management of Health Services System Economic Support of Health Services Production of Health Services Resources Delivery of Health Services

Part 1: Organization Ministry of Health—all levels Other Public Agencies Voluntary Agencies Enterprises Private Market

Part 2: Management Planning Administration Regulation Legislation

Part 3: Economic Support Personal Households Charity Insurance (voluntary) Social Security Governmental Revenues Foreign Aid

Part 4: Production of Resources Manpower Facilities Commodities (drugs, DME, equipment, etc.) Knowledge

Part 5: Delivery of Services Primary Care—Prevention Primary Care—Treatment Secondary Medical Care Tertiary Medical Care Care of Special Disorders and Populations

Applying Roemer at Home Part I: Organization of Health Services: US health system is DECENTRALIZED Department of Health and Human Services (DHHS) instead of MoH DHHS regulates and finances many health services Services delivery primarily occurs in private sector

Part I: Organization Public Health at the national level Centers for Disease Control and Prevention Food and Drug Administration Centers for Medicare and Medicaid National Institutes of Health Agency for Healthcare Research and Quality

Part I: Organization Voluntary Agencies Gap fillers Disease or interest group specific ACS, ARC, AARP Professional associations APHA, AHA, AMA Philanthropic and religious organizations Robert Wood Johnson

Part I: Organization Private Market Most health services provided in the private market Most health insurance provided in the private market Pharmaceuticals and supplies (developed and sold) Health professional training

Part 2: Management Planning: No centralized national-level planning authority Administration: More applied in nature at project or program level Legislation: all government units have authority to enact laws (budgeting process, restriction and limitations, new programs Regulation: Implementation of laws, licensure, certification, accreditation

Part 3: Economic Support Private Health Insurance (voluntary and employment related) largest source of funds (34%) to US health services ~70% of <65 have some type of health insurance Household/Out of Pocket: 15% Medicare: 17% Medicaid: 16% $1.3 trillion in 2000 16% of GDP in 2005

Part 3: Economic Support Where does the money go? 33% hospitals (50% of this from Fed.) 23% physician services 10% drugs 9% other personal care 7% nursing homes 6% program administration 3% research and construction 2% home health care

Part 4: Production of Resources Manpower: Health Services Industry Largest Industry in US: 11.9 million workers 800,000+ physicians 270.6 per 100,000 population 2:1 Specialist to Generalist practitioners Medicare subsidized training (GME/residencies) 2 million+ nurses: shortage, training variations Pharmacists, dentists, RT, OT, PT Health Administrators

Part 4: Production of Resources Hospitals: Various categories (I, II, III) & structures Merge and integrate to expand scope Financial challenges, cost shifting Prospective Payment, negotiated rates Biomedical Research and Technology: US most advanced on planet/ cost driver Drugs developed in private sector/FDA approval Most research publicly funded (via NIH) No clear chain of dissemination/assessment

Part 5: Delivery Systems Continuum of Care Prevention and Promotion: Public Sector Early Detection: Public and Private Primary Care: Private sector; PCP Secondary Care: Specialists/hospitals Tertiary Care: Academic Health Center Long Term Care: Medicaid is big payer Palliative Care: Home or Hospice Medicare $ for 80% Outside the continuum: chronic mental illness

Roemer Model MANAGEMENT ORGANIZATION OF DELIVERY RESOURCE OF SERVICES ORGANIZATION OF PROGRAMS MANAGEMENT ECONOMIC SUPPORT RESOURCE PRODUCTION

Conclusion Applying the Roemer Model to the US Healthcare System gives us a means to understand the system and make meaningful and direct comparisons. Skyrocketing costs, an aging population & a high percent of uninsured are issues of concern Quality-Access-Cost remain the overarching values of concern for the US healthcare system