MDCOR 850 Medical Care Delivery Systems

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): • Aug 15: • Aug 22: • • Aug 29: • Sept 5: • Sept 12: Introduction Insurance: The evolution of health care payment systems in the U.S. How the government pays for health care:Medicare/Medicaid Managed care and health financing Health systems in 3 industrialized nations 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 in the U.S. have nearly doubled from 1992- 2002 • At current rate, expected that costs will double again by 2012 (source CMS Office of Actuary, National Health Statistics Group, 2004) 3500 3000 2500 2000 1500 1000 500 0 1992 2002 2012 U.S. spends more than any other developed country 14 % of 12 10 8 6 4 2 0 U.S. Germany Canada France Sweden Japan UK G D P 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 1960 1980 Other 2001 Gov't 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% 20% 15% 10% 5% 0% Docs Hosp Phar Home NH Oth 1984 2004 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