Healthcare Delivery System Overview

Overview of the Health Care Delivery System

• Definition of Health Care Delivery System

  • Organization of people, institutions, and resources used to deliver services for health needs.

Components of the U.S. Health Care System

• Key Components:

  • Patients

  • Technology

  • Quality and Accreditation

  • Population Health

  • Healthcare Workers

  • Health Insurance and Cost

  • Healthcare Settings

  • Federal and State Funded Programs

Healthcare Delivery Complexity

• Complex System with many layers:

  • Roles:

    • Nurses provide nursing care (not medical care).

    • Physicians provide medical care and practice medicine.

    • Allied Health Professionals complement the roles.

  • Communication is key between providers and layers of care.

  • Focus on patient/client outcomes across all levels.

Levels of Healthcare Services

1. Tertiary Care

   • Advanced diagnostics and treatments or rehabilitation.

   • Goal: Restore health or quality of life.

2. Secondary Care

   • Diagnosis and treatment of acute illness.

   • Goal: Cure or restore optimal health.

3. Primary Care

   • First contact; focus on health promotion and disease prevention.

   • Goal: Encourage optimal health.

Nursing Roles and Work Settings

• Registered Nurses (RNs) are essential in all levels of healthcare.

• Work Environments:

  • Hospitals

  • Community clinics

  • Schools

  • Jails

  • Outpatient services, research facilities, home care, provider offices, etc.

  • Varied settings, including unique locations (e.g., cruise ships, military).

Members of the Healthcare Team

• Key Members:

  • Unlicensed Personnel

  • Nurses

  • Allied Health Professionals

  • Physicians

Quality and Access in Healthcare

• Institute for Health Care Improvement - Triple Aim:

  • Population Health, Per Capita Cost, Experience of Care

• Quadruple Aim: Supporting clinician experience alongside patient experience and cost improvement.

• Access Factors:

  • Funding, geography, trust, health literacy.

Paying for Healthcare in the U.S.

• Influencing Factors:

  • Payors, rising costs, regulation (both government and private).

• Health Insurance:

  • Spreads high medical costs among many via regular contributions.

  • Key terms: Premium, Deductible, Co-pay, etc.

Insurance Payment Models

1. Retrospective (Fee for Service):

   • Popularity in the 1960s; dictated by providers.

   • Lead to overuse and rapid cost inflation.

2. Prospective (Payment based on DRGs):

   • Initiated in the 1980s; dictated by insurance providers (e.g., Medicare).

   • Limits payments based on diagnosis-related groups.

   • Resulted in the development of Managed Care Organizations (MCOs).

3. Pay for Performance (PFP):

   • Financial incentives to providers for meeting performance measures.

Managed Care Organizations

• Types:

  • HMO: Directed care by a Primary Care Provider (PCP), referrals needed, and limited networks.

  • PPO: More choice for consumers with out-of-network options at a higher cost.

  • POS: Combination of HMO and PPO; includes the option to go out-of-network.

Patient Protection and Affordable Care Act

• Key Features:

  • Financial assistance to qualified households, mandated benefit packages, regulated spending by insurance companies, Medicaid funding expansion, etc.

Questions to Consider

• What drives the U.S Health Care System?

• What access issues do clients face?

• What happens due to inadequate primary care?

• What roles do RNs play in the healthcare system?

Discussion Prompts

• Share two points about the importance of primary care.

• Discuss barriers preventing clients from receiving primary care.