15 Healthcare Systems

Overview

  • Healthcare Systems in the U.S. and Beyond

  • Illness Representations

  • Anderson’s Behavioral Model

    • Factors that affect whether, how, when, and why people use healthcare

  • The Patient-Provider Relationship

  • Adherence to Treatment

  • Healthcare Reform

Healthcare Systems in the U.S. and Beyond

  • The U.S. spends more on healthcare than any other nation.

  • However, Americans use fewer healthcare services and have worse health and shorter life expectancies compared to citizens of other highly developed nations.

Global Healthcare Systems

  • Healthcare delivery systems around the world are modeled on a few basic designs:

    • Single provider:

      • Financing: General taxation, central government (United Kingdom) or local/regional government (Scandinavia).

      • Ownership: Public.

      • Private Insurance: Yes.

      • Examples: United Kingdom, Italy, Spain, New Zealand, Greece, Portugal, Norway, Sweden, Denmark, Finland, Ireland

    • National health insurance/single-payer:

      • Financing: General taxation, central government and/or regional government.

      • Ownership: Mixed public and private.

      • Private Insurance: No.

      • Examples: Canada, South Korea, Taiwan

    • Social insurance:

      • Financing: Mandated social insurance, typically funded by payroll taxes.

      • Ownership: Mixed public and private.

      • Private Insurance: Yes.

      • Examples: France, Germany, Holland, Switzerland, Belgium, Luxembourg, Japan

    • Pay-as-you-go:

      • Financing: Out of pocket.

      • Ownership: Mixed public and private.

      • Private Insurance: Yes.

      • Examples: Most developing countries

    • Pluralistic:

      • Financing: Mixed.

      • Ownership: Mixed public and private.

      • Private Insurance: Yes.

      • Examples: United States, Australia, Singapore

Pluralistic Healthcare System in the U.S.

  • Unique mixture of public, private nonprofit, and private for-profit healthcare

  • Compensation for physicians can come from insurance companies, directly from patients, or government programs.

  • Maintains many separate systems for different groups of people:

    • HMOs and PPOs (for most working adults/employees)

    • Medicare (for older adults)

    • Medicaid (for people with low incomes)

    • Veteran’s Health Administration (for veterans)

  • Employer/Employee-based

    • HMO and PPOs – employer and employee contributions

  • Medicare (people aged 65+)

    • Single-payer system (similar to system in Canada)

  • VHA (veterans)

    • Single-provider system (similar to systems in Cuba and UK)

  • No insurance (and ineligible for Medicaid)

    • Pay-as-you-go (similar to systems in developing countries)

  • Important to consider the type(s) of healthcare systems that a country has because it affects whether, how, when, and why individuals interact with that system.

Illness Representations

  • Illness representations: Our personal views of symptoms, health, and illness.

    • How a person interprets perceived causes, timeline, consequences, and controllability.

    • Our representations/perceptions affect:

      • How we react when symptoms occur

      • The types of health behaviors we engage in, including whether we seek medical care

Components of Illness Representations

  • Identity of the illness

    • We seek diagnostic labels.

    • We seek to identify symptoms that are consistent with those labels.

    • Illnesses are, to some degree, social constructions.

  • Causes

    • Individuals tend to attribute symptoms to external and internal factors.

      • External = infection, injury

      • Internal = genetic predispositions

  • Timeline

    • Beliefs that a condition is acute (short-term) or chronic (long-term)

  • Consequences

    • Perceptions of the physical, social, and economic impacts of symptoms

  • Controllability

    • Beliefs about whether the illness can be prevented, controlled, and/or cured

Example Symptoms

  • Symptoms: throbbing and pulsing pain in head, nausea, some vomiting, and increased sensitivity to sound and light

    • Identity – possible labels?

    • Causes – external and/or internal?

    • Timeline – acute or chronic?

    • Consequences – disrupts life a lot vs. a little?

    • Controllability – can symptoms be fixed?

Anderson's Behavioral Model

  • Theoretical framework for understanding access to and utilization of healthcare services, and to recognize the factors that impact a person’s decision to use or not use services

Factors

  • Predisposing Factors

    • Individual characteristics that influence propensity towards healthcare use

      • Demographic factors (e.g., age, gender)

        • Age: Youngest and oldest people use healthcare services most often.

        • Gender: Women are more likely to report symptoms, use services, and pay more for healthcare.

      • Social structures (e.g., education, occupation, citizenship)

      • Biological factors (e.g., genes)

      • Psychological factors (e.g., personality)

  • Enabling Factors

    • Resources of the individual, or the community to which they belong, that make it possible to access care

      • Personal/Family

        • Health literacy – people must know how to get services

        • Income

        • Health insurance

        • Social support

      • Community

        • Healthcare services must be available where someone lives (e.g., rural vs. urban)

        • Travel and waiting times

        • Culture and upbringing

  • Need-Based Factors

    • Perceived and objective health conditions requiring care

      • Illness representations (perceived)

      • Evaluated need (objective health conditions)

Delay Behavior

  • Tendency to avoid seeking medical care

  • Avoiding medical care can occur at five different points in the decision-making process

    • Appraisal delay: Notices unexplained symptoms?

    • Illness delay: Am I sick?

    • Behavioral delay: Do I need medical attention?

    • Scheduling delay: Schedules a physician visit?

    • Treatment delay: Receives medical attention?

  • The longer you wait, the more likely the condition will become serious and/or life-threatening.

  • When in doubt, please go!

Patient-Provider Relationship(s)

  • Quality of patient-provide relationship matters A LOT for healthcare use, diagnosis and treatment, adherence, and patient quality of life

  • Key factors that affect patient care and the patient-provider relationship

    • Discrimination, prejudice, and oppression

    • Patient qualities

    • Provider qualities

Discrimination, Prejudice, and Oppression

  • Are “baked into” the medical system

    • E.g., clinical formulas used to diagnose kidney disease and designate eligibility to receive kidney transplants

  • Are evident by the overrepresentation of white people in scientific medical research and clinical trials

  • Are rooted in historical (and current) traumas that make minoritized groups hesitant to seek and/or trust healthcare

    • E.g., Tuskegee Syphilis Study

    • E.g., Bathroom bills

  • Are perpetuated by healthcare providers in medical settings

    • E.g., Black women in the U.S. have the highest risk of death from child birth

    • E.g., Refusal to provide gender affirming care

  • Set the stage for the patient-provider relationship…

Patient and Provider Qualities

  • Patients

    • Need to seek care in the first place

    • Need to communicate symptoms clearly and accurately

    • Need to trust the physician and healthcare system, more generally

    • Health literacy helps

      • Ability to understand and use health care information to make decisions and follow instructions

  • Providers

    • Need to listen and ask questions

    • Need to communicate clearly, in depth, and with respect

    • Need to foster trust, care, empathy

    • Need to treat patient like a human rather than a business client

    • Need to take their time

    • Need to be trained in how to deliver bad news

    • Need to consider cultural context

    • Humility helps with all of the above

Adherence to Treatment

  • Adherence = closely following the advice of a healthcare provider

    • For example:

      • Taking medication and taking it as prescribed

      • Following up with primary care doctor after going to ER or urgent care

      • Following lifestyle recommendations to eat healthier, exercise more, etc.

      • Following pre-surgical guidance on food/water intake and post-surgical guidance on wound care

    • Altering the duration in which treatment is followed

  • Costs associated with non-adherence can be huge!

    • Approximately 30-50% of adults do not adhere to doctor’s instructions for medication use alone → estimated $100 preventable healthcare costs

Factors that predict adherence

  • Shorter duration → more likely to adhere

  • Higher complexity → less likely to adhere

  • Tailoring to person’s lifestyle → more likely to adhere

  • Involving support systems → more likely to adhere

  • Providing feedback about progress → more likely to adhere

  • Differences for types of treatment regimens (e.g., medications vs. lifestyle)

Healthcare Reform

  • Increasing overall access

    • E.g., Affordable Care Act

  • Collaborative Care, or Integrated Care: combined efforts of physicians, psychologists, and other providers – e.g., they talk to each other (WOW, revolutionary!)

  • Patient-centered care: delivery of healthcare services that are responsive to the individual patient’s preferences, needs, and values

  • Telemedicine and eHealth/mHealth services: delivery of medical information and clinical services through electronic means (which also increases accessibility)