Healthcare System

Introduction

• Health systems science (HSS) provides a framework to understand the interconnected components of the health system. HSS studies:^[5]
  • The delivery of health care
  • The ways health professionals work together
  • The means by which high-quality, high-value, equitable care is provided for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
• 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:^[3]
  • 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”^[2,5,6]
• Considered the 3rd pillar of medical education Medical education Conflict of Interest along with basic and clinical sciences
• Core Domains:
  • Healthcare structure and process:
    • Organization of individuals, resources, and processes for care delivery: care settings and transitions of care
    • Coordination Coordination Cerebellar Disorders of these components for the delivery of care to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
  • Healthcare policy and economics:
    • Decisions, plans, and actions taken to meet community healthcare goals
    • Studies the healthcare system structure, financing and regulations that direct the type of care delivered, the cost and the recipients.
  • 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 (non-medical factors that affect 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 health such as work and living conditions)
    • 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 while making decisions that balance cost and benefit
    • Optimize the outcomes, but also avoiding waste
    • 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
• Cross-cutting domains (skills used in each core domain):
  • Leadership and change agency:
    • Motivating others to pursue a common goal
    • Emerging key opinion leaders (KOLs) among medical and surgical subspecialties:
      • Development of consensus guidelines
      • Development of standardized quality measures Quality Measures Quality Measurement and Improvement or quality improvement Quality improvement The attainment or process of attaining a new level of performance or quality. Quality Measurement and Improvement projects
      • 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
    • Teamwork/teaming:
      • Collaboration to achieve shared goals
      • Development of coordinated care teams
      • Development of clinically integrated networks (CINs)
    • Evidence-based medicine and practice:
      • Define high-value care
      • Appraise and measure population health interventiosn
    • 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 professionalism:
      • 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
• Linking domain:
  • Systems thinking:
    • Solve problems in healthcare utilizing knowledge of how these domains interact
    • Emerging system of integrations, checks, and balances

Models of Health Systems

General models^[3]

• Beveridge model:
  • Healthcare is paid for and provided by the government.
  • Funding Funding Conflict of Interest: through taxation
  • Delivery:
    • 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.
  • Features:
    • Makes healthcare affordable because the state sets the price
    • Universal coverage; free at point of use
  • Examples:
    • UK National Health Services (NHS)
    • US Veterans Administration ( VA VA Ventilation: Mechanics of Breathing)
    • New Zealand
    • Spain
• Bismarck model:
  • Healthcare paid for by nonprofit insurances
  • Funding Funding Conflict of Interest: financed by employee, employer contributions (payroll-based), and general tax revenue
  • Delivery: service provided by private and public sectors
  • Features:
    • Universal coverage via mandatory enrollment
    • Insurances must cover everyone and are nonprofit.
  • Examples:
    • Netherlands
    • Switzerland
    • France
    • Germany
    • Japan
• National health insurance or single-payer model:
  • Healthcare paid for by a single government-run insurance
  • Funding Funding Conflict of Interest: financed by taxation/citizen contributions
  • Delivery: service provided in private and public sectors
  • Features: universal coverage
  • Examples:
    • Canada
    • US Medicare
    • South Korea
    • Taiwan
• Out-of-pocket model:
  • Healthcare paid for by the consumer
  • Funding Funding Conflict of Interest: individual payment
  • Delivery: service provided by private and public sectors
  • Features:
    • Little to no insurance coverage
    • Low- and middle-income countries
  • Examples:
    • Rwanda
    • India
    • Chad

In the United States:

Mixed system is seen in the U.S., combining features of the different models.

• Bismarck model: working citizens under 65 years of age obtain health coverage (mostly private insurances) and funding Funding Conflict of Interest is through payroll deduction.
• National health insurance: citizens 65 years and above utilize Medicare.
• Beveridge model: Veterans Health Administration (government) provide coverage for military members and veterans
• Out-of-pocket model: uninsured individuals pay cash for medical services.

Healthcare Structure and Process

• Nested model of healthcare structure:^[7]
  • Patient:
    • At the center of care
    • The patient is empowered to be a key player in healthcare decision making.
  • Care team:
    • Professional care providers ( physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship, nurses, pharmacists, others)
    • Patient self-care
    • Family members
  • 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 (moving the patient through the nested structure):
  • Evaluation, testing, treatment, surgery, medication administration
  • Transfer to alternative facilities (i.e., more advanced resources, higher level of care)
  • Admission/discharge
  • Transition of care:
    • Occurs from provider-to-provider, unit-to-unit and/or facility-to-facility
    • 1 in 5 patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have an adverse event within 1 month of hospital discharge, so it is crucial that patient/caregiver education, medication reconciliation, structured follow-up are set up.

Healthcare Delivery Systems^[4]

• Health maintenance organization (HMO):
  • Provides designated services for a prepaid premium
  • Serves a geographic area (service area/enrollment area)
  • 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
  • Referrals from 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) are not needed as long as the specialist is in-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 on televisits is a part of a broader care model.
  • Services limited to conditions not requiring in-person visits
• Concierge services:
  • Individual or group of providers
  • Flat monthly/annual payment in exchange for medical services
  • In most models, this fee is separate from and in addition to the insurance billing for covered services.