intro 20session

							MDCOR 850: Medical Care
   Delivery Systems
         Course introduction
• What are the goals and expectations for this
  course?
• What is the schedule of topics?
• What is a “health systems” anyway?
• What are the key components of a health system
  and what are they like in the U.S.?
• What do we get from our “health system?”
       Educational objectives for
            MDCOR850
• Understand how the US health care system is
  constructed and how if differs from other
  countries.
• Understand how payment mechanisms work.
• Describe quality and variation in health care.
• Become familiar with different health care
  providers in the United States and their role in
  the health system.
• Understand care for special populations
  Course requirement Number 1
• Attend 14 of the Wednesday afternoon sessions
  – These do not have to be in a row and you don‟t need
    to call or contact me if you can‟t make it
  – Please remember to sign in each week so I know that
    you were there
  – Try to stay awake and look attentive (“and” not
    “or”), especially for invited speakers
  – If you are interested in a topic and want the
    speaker‟s presentation emailed to you, just let me
    know and I will send it to you
  Course requirement Number 2
• Write a paper about a health policy topic to be
  turned in by March 30
  – The paper should be 3 to 5 pages long
  – It should cover a health policy/health systems topic
    related to one of the sessions during the year
  – It should address a specific question or issue in
    health systems/policy
  – It must include at least 3 published references to
    demonstrate that you did some reading beyond the
    class
    Final papers: selected topics
• How is the medical liability crisis effecting patients‟
  access to care and physician practice variation?
• Towards a national electronic health record
• Why competition has failed in health care
• The current state of several large pharmaceutical
  company stocks
• A look at telemedicine and rural health care
• Psychiatric treatment disparities
• Models of multidisciplinary women‟s health care which
  include mental health services
• Why are nurses so bitchy?
   What do I have to actually do?
• Show up for the sessions
• Do any reading
  recommended before the
  topic so you can
  participate in the
  discussion
• Write the paper
          When will we meet?
• Every Wednesday from 4 to 5:30 (latest)
• We will NOT MEET:
  – November 7
  – November 21 (day before Thanksgiving)
  – Any Wednesday in December
• Last meeting will be March 26, 2008
• Total of 28 meetings: you have to attend half
   Other opportunities for credit
• From time to time during the semester other
  meetings outside of normal class time will count
  towards credit for this course
• Also have opportunity for special sessions: 1st
  will be the CCMS Legislative Reception
  (held in October)
• Others include future Charleston County
  Medical Society meetings, some special
  seminars, or other meetings.
             Course Web site
• Please check the course web site
  http://www.musc.edu/dfm/Medstuds.htm for
  information
• Schedule of future topics will be posted on this
  site
• Slides will be posted for selected presentations
  so you can look up old materials if you are
  interested
Overview of Course Organization
Organized into 5 general areas:
• Part 1: The US Health System and Payers
• Part 2: Quality, variation, and malpractice
• Part 3: Physician financial issues
• Part 4: Health care providers in the US
• Part 5: Health Care for Special Populations
      What is the schedule like?
• Aug 8 (today):   Introduction
• Aug 15:          Insurance: The evolution of health
                   care payment systems in the U.S.
• Aug 22:          How the government pays for health
•                  care:Medicare/Medicaid
• Aug 29:          Managed care and health financing
• Sept 5:          Health systems in 3 industrialized
                      nations
• Sept 12:         Health system reform movements
      What is a health system?
• “The United States has a unique system of
  health care delivery…. The U.S. health care
  delivery system is not a system in the true
  sense…. Hence, it may be somewhat misleading
  to talk about the American health care „system‟
  because a real system does not exist….”
                      Shi & Sing
                      Delivering Health Care in
                      America
         What is a “system”?
• HEALTHCARE SYSTEM: A network of
  integrated components designed to work
  together coherently
   What is a healthcare system?
• HEALTHCARE SYSTEM: A network of
  integrated components designed to work
  together coherently
   What do we have in the U.S.?
• U.S. “SYSTEM”: Hodgepodge of financing,
  insurance, delivery, and payment
  mechanisms that remain unstandardized and
  loosely coordinated… The system is functionally
  fragmented because it is not subject to overall
  planning, direction, and coordination from a
  central agency.
            Some definitions
• Financing: system that puts in the money so
  that people can get health care
• Insurance: system that protects insured person
  from catastrophic risk
• Delivery: system that provides health care either
  in ambulatory, hospital, or home setting
• Payment: actual reimbursement system for the
  provider for the care that is rendered
                          Financing
• Health care expenses           3500
  in the U.S. have               3000
  nearly doubled from
                                 2500
  1992- 2002
                                 2000
• At current rate,
                                 1500
  expected that costs
  will double again by           1000

  2012                           500
(source CMS Office of Actuary,     0
   National Health Statistics           1992   2002   2012
   Group, 2004)
     U.S. spends more than any other
            developed country
     14

     12
%
     10
of
     8

     6
G
D    4
P
     2

     0
          U.S.   Germany Canada   France   Sweden   Japan   UK
    Put another away: how much do we
         spend per person per year
    5000
    4500
    4000
    3500
$   3000
    2500
    2000
    1500
    1000
     500
      0
           US   Switz   Norway   Ger   Canada   Japan   UK
Where does this money come from?
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
          Pocket           Insurance           Other              Gov't

  Source: Centers for Medicare and Medicaid, Office of the Actuary, Year 2001
How has that changed over time?
60%

50%

40%

30%

20%

10%

0%
      Pocket   Insurance           Other   Gov't

                 1960      1980   2001
                    Financing
• How does money get put into system
• Three primary sources:
  – Employers: pay the most for health care
  – Government: soon will become the major payer
    (already the primary payer if count all federal, state,
    and local employees)
  – Individuals: out of pocket expense growing
                    Insurance
• U.S. insurance “system” is an uncoordinated
  patchwork of programs:
  – Employer-based insurance
  – Federal insurance programs:
     • Medicare
     • Medicaid
     • Public health programs
• Concept of insurance has changed: no longer for
  “catastrophic care”– now thought to take care
  of all care, even routine or discretionary care
               Delivery system
• System of health care providers:
  –   Doctors                  - Hospitals
  –   Pharmaceuticals         - Nursing homes
  –   Home health             - Durable goods
  –   Alternative health providers
• Most are independent of one another
• Few “vertically integrated systems,” i.e. one
  system includes doctors, hospital, home health,
  durable medical goods, etc.
  Everyone wants a slice of the pie:
  comparison of 1994 and 2004 (est)
45%
40%
35%
30%
25%                                          1984
20%                                          2004
15%
10%
5%
0%
      Docs   Hosp   Phar   Home   NH   Oth
             Reimbursement
• Multiple systems exist for reimbursement to
  providers (you) and hospitals:
  – Fee-for service (rare)
  – Discounted/negotiated fee-for-service
  – Capitation
      So how good is this system?
• WHO (World Health Organization) rankings of
  countries health care system performance:
  –   1st: France
  –   2nd: Italy
  –   3rd: San Marino
  –    …….
  –   35th: Dominica
  –   36th: Costa Rica
  –   37th: United States
  –   38th: Slovenia
 So what do we get from all this?
• U.S. ranking on selected health outcomes among
  13 industrialized nations:
  –   13th in low-birth-weight mortality
  –   13th in years of potential life lost
  –   11th in life expectancy for females at 1 year of age
  –   12th in life expectancy for males at 1 year of age
  –   3rd for life expectancy at 80 years for female
  –   3rd for life expectancy at 80 years for males
   Why is this of concern to us?
• “Systems are perfectly designed to achieve the
  outcomes they produce.” Donald Berwick
• Understanding the systems will help prepare you
  to deal with it
• Understanding the systems involved will help
  prepare you to change it