MDCOR 850: Medical Care Delivery Systems

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MDCOR 850 Medical CareDelivery Systems
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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?

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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

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Course requirement Number 1

• Attend 14 of the Wednesday afternoon sessions
• These do not have to be in a row and you dont
  need to call or contact me if you cant 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
  speakers presentation emailed to you, just let
  me know and I will send it to you

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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

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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 womens health care
  which include mental health services
• Why are nurses so bitchy?

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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

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When will we meet?

• Every Wednesday from 4 to 530 (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

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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.

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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

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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

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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
• careMedicare/Medicaid
  
• Aug 29 Managed care and health financing
• Sept 5 Health systems in 3 industrialized
• nations
• Sept 12 Health system reform movements

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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

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What is a system?

• HEALTHCARE SYSTEM A network of integrated
  components designed to work together coherently

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What is a healthcare system?

• HEALTHCARE SYSTEM A network of integrated
  components designed to work together coherently

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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.

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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

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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)

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U.S. spends more than any other developed country
of GDP
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Put another away how much do we spend per person
per year

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Where does this money come from?
Source Centers for Medicare and Medicaid, Office
of the Actuary, Year 2001
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How has that changed over time?
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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

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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

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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.

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Everyone wants a slice of the piecomparison of
1994 and 2004 (est)
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Reimbursement

• Multiple systems exist for reimbursement to
  providers (you) and hospitals
• Fee-for service (rare)
• Discounted/negotiated fee-for-service
• Capitation

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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

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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

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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