US Health Care Systems Exam 1

What does the quad function model represent?

The key functional components of any health care delivery system

What are the components of the quad function model?

1. Financing: purchase insurance or prepare to pay for health care

2. Insurance: protects against catastrophic risk

3. Delivery: given by a provider

4. Payment: reimbursement

What are the primary characteristics of the US Health Care system that differentiate it from other nations?

• No central agency/national healthcare system

• Partial access

• Imperfect market

• Third party insurers and payers

• Multiple payers

• Power balancing

• Legal risks

• High technology

• Continuum of services

• Quest for quality

What does “imperfect market” mean?

The U.S. health care system, is partially managed by free market

What is supplier/provider induced demand?

Physicians(suppliers) have influence on creating demand for their financial benefit

What is item pricing?

Services can’t be determined prior to delivery/procedure

What is package pricing?

A bundled fee for a group of related services

What is power balancing?

There are multiple “players” in the health care system(physicians, admin, insurance, gov) that have fragmented self interest that prevents system wide reform

What should be the primary objectives of any health care system?

• To enable all citizens to receive health care services

• To deliver services that are cost effective and meet established standards of quality

What is the difference between illness and disease?

• Illness is identified by a person’s perception of how they’re feeling(diminished capacity to perform expected tasks/roles)

• Disease is based on a professional evaluation

What is utilization?

The consumption of health care services or the extent to which services are used

What does the Activities of Daily Living Scale evaluate?

• Feeding

• Bathing

• Dressing

• Using toilet

• Transferring

• Grooming

• Walking eight feet

What does IADL(Instrumental Activity of Daily Living) evaluate?

• Using phone, transportation

• Shopping

• Prepare meals

• Doing heavy housework

• Taking meds

• Handling money

• Walking on stairs

• Walking ½ mile without assistance

What are the components of the Tripartite Model of Disease Occurrence?

Host(the organism), agent(the risk factor), and environment

What factors help exam disease occurrence?

Genetics, fitness, diet, tobacco use, socioeconomic factors, sanitation

What are the components of Blum’s Environment of Health-Factors?

Force fields: environment, lifestyle, heredity, medical care

What are the components of the Social Determinants of Health(WHO Commission)?

• Socioeconomic and political context

• Governance

• Policy

• Social/cultural norms

What are the core American beliefs in health care?

Advancement of science, capitalism, entrepreneurial spirit, concern for the underprivileged, free enterprise and distrust of government

What are the two theories of equitable distribution?

• Market Justice(Economic Good)

• Social Justice(Social Good)

What is the market justice theory?

Health care is an economic good governed by free market forces and supply/demand; works best without interference from the government

What is the social justice theory?

Health care is a social good; should be collectively financed and available to every citizen

• Equitable distribution of health care is society’s responsibility; works best with a central agency

What is Health People 2030?

A national initiative aimed at improving health of all Americans by 2030; focused on integration of care and prevention, health promotion, and education

What is the Pure Food and Drug Act(1906)?

Enforced accurate labeling on food and drugs

What is the Social Security Act(1935)?

• Federal aid to states for public health, welfare, maternal/child health, and crippled children

• Legislative basis for welfare programs like Medicare and Medicaid

What is Medicare?

• Created by XVII of the Social Security Act

• Federal government became responsible for health care of elderly

• Expanded in 1972 to include disabled and end stage kidney disease

What is Medicaid?

• Created by Title XIX; originally based on predetermined income level and age, but now extended to all age groups

What is the Medicare Modernization Act?

Provides reimbursement for MTM, but did not codify pharmacists as the only ones to provide

What positives came out of the Affordable Care Act?

• Health care spending growth per person slowed for 5 years

• Percentage of uninsured Americans decreased

• Access to health insurance with pre-existing conditions

• Hospitals in Medicaid expansion states had lower cost of care for low income patients

• Slowdown in health care spending growth

What private health plan reforms came with the ACA?

• Young adults can stay on their parents’ plan until 26

• Rescission ban

• Cannot be denied coverage due to pre-existing conditions

• Access to wellness and prevention without cost-sharing

• Banning lifetime caps and annual caps on major medical coverage

• Limit on premiums spent on admin costs

What were the limitations of the ACA?

• Higher premiums in areas where there is little to no competition between health insurance carriers

• Difficulties in affording premiums for those who don’t qualify for subsidies or Medicaid

• Funding shortfall in the Risk Corridor program

• Higher risk pools have resulted in several health insurers scaling back participation in the Exchange

What is the American Rescue Plan(ARPA)(2021)?

• Removed upper income limit on subsidies

• Increased the amount of financial assistance for people who were already eligible

What is the Inflation Reduction Act(2022)?

• Continued the subsidies in the ARPA through 2025

• Prevented hikes in premium payments enrollees would have faced if ARPA expired

• Requires federal government to negotiate prices for top selling drugs covered under Medicare ★

• Requires drug companies to pay rebates if prices rise faster than inflation for drugs used by Medicare beneficiaries ★

• Limits monthly cost sharing for insulin products

• Eliminates cost sharing for adult vaccines under Medicare Part D

What is the One Big Beautiful Bill Act(2025)?

• Over $1 trillion in spending cuts to health care through 2034

• Cut federal support for Medicaid and who is eligible Medicaid and Medicare benefits which

What major forces might influence health policy moving forward?

• Social and demographic: U.S. becoming bigger/older/more diverse, expanding gov. programs on unsustainable path, uninsured illegal immigrants

• Political

• Economic

• Technological

• Ecological

• Antho-cultural

What is the difference between public and health policy?

• Public policy: principles and standards regarded by the government intended to direct or influence actions of others

• Health policy: aggregate of principles, stated or unstated, that characterize the distribution of resources, services, and political influences that impact the health of the population

Who influences health policy?

Government, healthcare providers, government, advocates, tech companies, patients and caregivers

How does regulatory health policy impact the public?

• Prescriptive: government prescribes and controls behavior of a specific target group by monitoring the group and imposing sanctions if it fails to comply

• Self-regulatory: peer or non-governmental groups set standards for a given industry to abide by through accreditations, quality measurements, and commissions

How does allocative health policy impact the public?

• Distributive: spreads benefits throughout all society

• Redistributive: provides benefits to only a specified group

Explain the health policy cycle?

Identify the issue→design the policy→build partner/public support→advocate for legislative/regulatory adoption→implementation of policy

What is the fee-for-service model?

Lack of private health insurance or government sponsored health care system

What is the national health insurance model?

The government finances health care through taxes; care provided by private providers

What is the national health service model?

The government finances health care through taxes and manages the infrastructure for delivery; most providers are government employees

What is the socialized health insurance model?

Financed through government mandated contributions by employers and employees; health delivered privately, government exercises overall control

How does health care differ in Canada?

• Delivery: has national health insurance, most Canadians have private insurance for outpatient prescription drug coverage

• Financing: universal insurance paid for by personal and corporate taxes; set fees for medical services and drug prices

• Limitations: most hospitals at capacity, wait lists for common process urges, drug spending increasing, slow change

How does health care differ in Germany?

• Delivery: hospitals are a mix of public and private workers

• Financing: pay roll taxes, welfare orgs, pension funds, etc. fund the health system

• Limitations: higher ratio of hospital beds per person→higher operating costs, potential oversupply of physicians, over utilization of health care services; slowdown of economy puts strain on system

How does health care differ in England?

• Delivery: general practitioners are private contractors or salaried employees that work for the government

• Financing: national health service; universal comprehensive service financed through general taxes with minimal to no charges at point of service

• Limitations: advancements in tech and aging population have led to budget constraints, waiting lists for some hospital services, many travel to foreign countries for health care if they can afford it

How does health care differ in Cuba?

• Delivery: Family Physician Program, polyclinics; internationalist focus in work force training

• Financing: socialized health insurance; government has full control of health care

• Limitations: trade embargo affected flow of medical supplies→reduced surgical rates and use of lab services, inability to purchase half of new world-class drugs, housing shortage and scarcity of food impacted system and outcomes

What types of health care system models do we have in the U.S.?

• National Health Insurance(like Canada): elderly and disabled receive Medicare

• Decentralized National Health Program(like Germany): working Americans receive insurance benefits through their employment

• Socialized Medicine(like England and Cuba): veterans, military, and Native Americans receive health care through NHS like system

• Out of pocket model: uninsured Americans

What are some common approaches to drug price control in nations across the world and how does that differ from the U.S?

• Setting a maximum price of drugs and reimbursement, utilizing an economic committee

• UK has limit on maximum amount of profit a pharmaceutical company or pharmacy can make in a certain period of time

• The U.S. does not have set prices for services or medications

What is outpatient/ambulatory care?

Diagnostic and therapeutic services provided to the patient; does not require overnight inpatient stay

• Ex: physicians’ office, clinic, outpatient surgery centers

What is primary care focused on?

Prevention, diagnostic, therapeutics, health education, counseling, minor surgery

Identify reasons behind the growth in outpatient services

1. Hospital inpatient services are declining

2. Development of new tech has made some surgical procedures less invasive and allowed for outpatient

3. Utilization controls: inpatient hospital stays are discouraged by third party payers

4. Patient preference for outpatient care

5. Merging of organizations

Give examples of private practice

Office based physicians(limited examination and testing, short visits)

Give examples of hospital based outpatient services

Specialty clinics, family medicine clinics

Give examples of free-standing facilities

Walk-in clinics, urgent are centers, surgi-center

Give examples of Mobile Medical and Diagnostic and Screening

Ambulances with emergency medical techs; provide mammography, MRI, lithotripsy

What is ambulatory long-term care?

Nursing homes, case management, adult health day care

What is hospice?

Method of care, not a location; services for terminally ill with life expectancy of six months; pain management and psychosocial support

What are examples of public health service?

Typically provided by local health departments; family planning services, Tb screening, ambulatory mental health

What are community health centers?

Made to serve the medically underserved; oversight provided by government

What are the differences between primary, secondary, and tertiary care?

• Primary: prevention, diagnostic, therapeutic, health education, counseling, minor surgery

• Secondary: sporadic consultation from specialist, routine surgery, rehabilitation, emergency services, imaging; usually short term

• Tertiary: most complex; uncommon conditions that may include long term care

Describe the domains of primary care

• First contact: goal of primary care is accessibility!

• Continuous: care should occur over time for prevention and injury

• Coordinated: refer patients to specialized care, give advice, ensure comprehensiveness

• Comprehensive care

Identify various provisions in the ACA that apply to outpatient services

All ACA plans include: ambulatory services, emergency services, hospitalization, maternity care, mental health/substance abuse services, prescription drugs, rehabilitation, lab services, preventive and wellness services and chronic disease management, pediatric services