1. Understanding Health Systems: The Organization of
Chapter 1
Understanding Health Systems: The Organization of
Health Care in the United States

2. Reference Table 1.1 The Development of Health Care:
Epidemics of acute infections due to unsanitary living conditions. :
Development of scientific medicine and the beginning of governmental and societal intervention.

3. Reference Table 1.1 The Development of Health Care:
Shift from acute illnesses to chronic illnesses
Classic model of illness
Development of health insurance, and the explosion of medical technology.

4. Reference Table 1.1 The Development of Health Care
1980-present:
Chronic diseases now include illnesses related to environmental hazards and working conditions, a rapid growth in costs due to technology, and an increase in governmental influence.

5. Social Organization 1850-1900: 1900-1941: Mid 1960’s:
No formal structure. :
The development of local hospitals and health insurance plans.
Mid 1960’s:
Implementation of Medicare and Medicaid insurance programs.

6. Three Perspectives on the American Health Care System
Public policy perspective
Management strategy perspective
Clinical/patient perspective

7. Public Policy Perspective
U.S. health care system is comprised of five individual sub-systems:
Employment-related system
Poor and uninsured system
Veterans Administration system
Worker’s compensation system
Active duty military system

8. The Employment System
Covers approximately two-thirds to three-quarters of the total American population.
Finances one-third of health care expenditures.
Collection of private employers providing health insurance in the private sector.

9. The Poor and Uninsured System
Local governments supported by taxes and individual incomes are the sources of financing.
Services are provided by safety-net providers and local hospitals in the public sector.

10. The Poor and Uninsured System
Individuals who qualify for state Medicaid programs may obtain care in the private sector.

11. The Veterans Administration System
National system operated by the federal government.
Financed by federal tax revenues.
Coverage is only available to military veterans based on length of service or service-connected disability.

12. The Workers’ Compensation System
Care is provided to individuals who suffer from injuries or illnesses related to work environments.
Insurance benefits include direct financial support for living expenses and health care.
Both the employer and the employee share the cost of the insurance.

13. The Active Duty Military System
Care is financed and provided entirely by the military system for active-duty members.
Private insurance is provided to cover dependents.
Dependents may receive care from hospitals and physicians in the private sector or within the military system.

14. Management Strategy Perspective
In the 1980s
Employers began to demand that insurance companies constrain the rising costs of health insurance premiums.
Employers began utilizing managed care policies to reduce their costs.

15. Management Strategy Perspective
This resulted in a major shift from a “provider-controlled” health care system to a “payer-controlled” system.

16. The Clinical Perspective
How patients obtain care
Basic service components provided to the patients
Perceived quality of care and patient satisfaction

17. Table 1.2 The Basic Service Components
Health Promotion
Emergency Medical Services
Ambulatory Care for Simple/Limited Conditions
Ambulatory Care for Complex/Continuing Conditions
Inpatient Care for Single/Limited Inpatient Conditions
Inpatient Care for Complex/Multiple Inpatient Conditions
Long-term care (either in-home or institutional services)
Services for Social/Psychological Conditions (both inpatient and outpatient)
Rehabilitation services (both inpatient and ambulatory)
Dental Services
Pharmaceutical Services

18. Table 1.3 Factors Affecting Utilization Rates
Consumer
Provider
System
Signs and symptoms
Access mechanisms
Contractual arrangements
Beliefs
Provider incentives
Payment mechanisms
Insurance coverage
Operational systems
Legal considerations
Income and wealth
Technology and medical information
Networks and providers
Information access and knowledge
Referral arrangements