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

2. 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

3. 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

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

5. 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

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

7. Part 2: Management
Planning
Administration
Regulation
Legislation

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

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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

22. 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