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Healthcare System

Healthcare System

The complexity of health systems and the delivery of healthcare has resulted in the growing field of health systems science, which has now joined basic and clinical sciences as the 3rd pillar of medical education. Health systems science allows for an understanding of the framework in which care providers practice, and comprehension of the interconnected components of care delivery. Effective communication and collaboration within this context are essential for providing quality healthcare. The patient is at the center of a nested model of healthcare surrounded by the care team, the supporting organizational infrastructure, and the political environment. Models of health systems are defined by the ways in which healthcare is paid for, financed, and delivered. Healthcare delivery systems are further defined by a network of providers, affiliated organizations, and financial structures.

Last updated: Dec 13, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Contents

Introduction

  • Health systems science provides a framework to understand the interconnected components of the health system.
  • Communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence, collaboration, and context are essential for the delivery of quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement healthcare.
  • Models for health systems are based on the way in which healthcare is paid for, financed, and delivered:
    • Beveridge model
    • Bismarck model
    • Single-payer model
    • Out-of-pocket model
  • Healthcare delivery systems are defined by the network of organizations and providers of care within a given financial structure, such as Health Maintenance Organization (HMO) and Integrated Delivery System (IDS).

Health Systems Science

  • Defined as “the principles, methods, and practice of healthcare delivery”
  • A framework for how care is delivered to meet the needs of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship or populations
  • The manner in which professionals work together to improve patient care
  • The 3rd pillar of medical education Medical education Conflict of Interest along with basic and clinical sciences
  • Domains of health systems science:
    • Healthcare structure and process:
      • Organization of individuals, resources, and processes for care delivery
      • Coordination Coordination Cerebellar Disorders and collaboration necessary for the delivery of care
    • Healthcare policy and economics:
      • Decisions, plans, and actions taken to meet community healthcare goals
      • Efficiency and effectiveness
    • Clinical informatics and health technology:
      • Electronic health records, documentation Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature. It often involves authenticating or validating information. Advance Directives, and decision support
      • Analysis of data for healthcare improvement
    • Population, public, and social determinants of health:
      • Strategies to improve population health
      • Consideration of social determinants of health
      • Measuring and monitoring key health metrics
    • Value in healthcare:
      • Delivery of quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of care divided by the cost of care over time
      • Health economics outcomes research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest (HEOR) is an emerging branch of health science.
    • Health system improvement:
      • Measuring and analyzing the quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of care delivery
      • Setting goals for improvement, implementing interventions, evaluating effectiveness, and continual improvement
    • Leadership:
      • Motivating others to pursue a common goal
      • Emerging key opinion leaders (KOLs) among medical and surgical subspecialties:
    • Teaming:
      • Collaboration to achieve shared goals
      • Development of coordinated care teams
      • Development of clinically integrated networks (CINs)
    • Change agency, management, and advocacy:
      • Knowledge and skills required to act as a change agent
      • Patient advocacy to improve healthcare services for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
      • Deliver the best quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of care
    • Ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Medical Ethics: Basic Principles and legal:
      • Ethical and legal issues involved in healthcare delivery
      • Administrative codes set by the state medical boards
      • Medicolegal review committees integral to pharmaceutical, biotechnology, and medical device industries
    • Systems thinking:
      • An understanding of how these domains interact
      • Emerging system of integrations, checks, and balances
Health systems science domains

Health systems science domains

Image by Lecturio.

Models of Health Systems

  • Beveridge model:
    • Healthcare is paid for and provided by the government:
      • Funded through taxation
      • The state owns most of the healthcare infrastructure and employs the healthcare providers.
      • Some private entities still exist and bill the state directly for services.
      • Makes healthcare affordable because the state sets the price
    • Examples:
  • Bismarck model:
    • Healthcare paid for by nonprofit insurance
    • Financed by employee, employer contributions, and general tax revenue
    • Service provided by private and public sectors
    • Examples:
      • Netherlands
      • Switzerland
      • France
      • Germany
      • Japan
  • National health insurance or single-payer model:
    • Healthcare paid for by government-run insurance programs
    • Financed by taxation
    • Service provided in private and public sectors
    • Examples:
      • Canada
      • US Medicare
      • South Korea
  • Out-of-pocket model:
    • Healthcare paid for by the consumer
    • Service provided by private and public sectors
    • No insurance coverage
    • Low- and middle-income countries
    • Examples:
      • Rwanda
      • India
      • Chad

Healthcare Structure and Process

  • Nested model of healthcare structure:
    • Patient:
      • At the center of care
      • The patient is empowered to be a key player in healthcare decision making.
    • Care team:
    • Organization:
      • Hospitals, ambulatory surgical centers, doctor’s offices, nursing homes
      • Infrastructure that supports the work of the care team
    • Political environment:
      • Conditions under which the care team and organization operate
      • Legal and regulatory entities oversee and administer the delivery of healthcare.
  • Healthcare processes:
    • Evaluation, testing, treatment, surgery, medication administration
    • Transfer to alternative facilities (i.e., more advanced resources, higher level of care)
    • Admission/discharge
A four level conceptual health model (1)

A 4-level conceptual health model

Image by Lecturio.

Healthcare Delivery Systems

  • Health maintenance organization (HMO):
    • Provides designated services for a prepaid premium
    • Serves a geographic area known as a jurisdiction
    • Primary care provider ( PCP PCP Pneumocystis jiroveci is a yeast-like fungus causing pneumocystis pneumonia (PCP) in immunocompromised patients. Pneumocystis pneumonia is spread through airborne transmission and classically affects patients with AIDS, functioning as an AIDS-defining illness. Patients may present with insidious onset of fever, chills, dry cough, chest pain, and shortness of breath. Pneumocystis jirovecii/Pneumocystis Pneumonia (PCP)) evaluates and treats.
    • Referral initiated by PCP PCP Pneumocystis jiroveci is a yeast-like fungus causing pneumocystis pneumonia (PCP) in immunocompromised patients. Pneumocystis pneumonia is spread through airborne transmission and classically affects patients with AIDS, functioning as an AIDS-defining illness. Patients may present with insidious onset of fever, chills, dry cough, chest pain, and shortness of breath. Pneumocystis jirovecii/Pneumocystis Pneumonia (PCP), as needed, to specialist providers within the network
  • Exclusive provider organization ( EPO EPO Glycoprotein hormone, secreted chiefly by the kidney in the adult and the liver in the fetus, that acts on erythroid stem cells of the bone marrow to stimulate proliferation and differentiation. Erythrocytes: Histology):
    • Managed care plan
    • Covers providers only within a specific network
  • Integrated delivery system (IDS):
    • A single or group of organizations coordinating and integrating delivery of care
    • Ambulatory and tertiary-care services included
  • Preferred provider organization (PPO):
    • Services rendered by preferred provider network
    • Referral not required for specialist care
    • Services outside of the network have additional out-of-pocket costs.
  • Point-of-service (POS) plan:
    • Hybrid of HMO and PPO
    • PCP PCP Pneumocystis jiroveci is a yeast-like fungus causing pneumocystis pneumonia (PCP) in immunocompromised patients. Pneumocystis pneumonia is spread through airborne transmission and classically affects patients with AIDS, functioning as an AIDS-defining illness. Patients may present with insidious onset of fever, chills, dry cough, chest pain, and shortness of breath. Pneumocystis jirovecii/Pneumocystis Pneumonia (PCP) is still required for referral to specialist
    • Access to physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship both in and out of network, but out of network costs more
    • Higher cost premiums, deductibles, and coinsurance
  • Telemedicine services:
    • Video and phone technology used to increase ease and access to care
    • Care delivery based exclusively on televisits
    • Services limited to conditions not requiring in-person visits
    • Organizations, individuals, and health plans finance these benefits.
  • Concierge services:
    • Individual or group of providers
    • Flat monthly payment in exchange for medical services

References

  1. American Medical Association. Health Systems Science. Retrieved December 15, 2021, from: https://www.ama-assn.og/topics/health-systems-science
  2. Reid, P.P., Compton, W.D., Grossman, J.H., et. al.; Editors (2005). A Framework for a Systems Approach to Health Care Delivery. National Academy of Engineering (US) and Institute of Medicine (US) Committee on Engineering and the Health Care System; Washington (DC): National Academies Press (US).
  3. Types of Health Systems. Columbia Comparative Health Policy Library. Last Updated: Sep 30, 2021. Retrieved December 15, 2021, from https://www.publichealth.columbia.edu/research/comparative-health-policy-library/types-health-systems-0
  4. Medicare Supplement. 7 Common Health Care Delivery Models Explained. Retrieved December 15, 2021, from https://www.medicaresupplement.com/coverage/health-care-delivery-models-explained/
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