American Healthcare Presentation

American Healthcare Presentation By: Caroline, Ceniya, Claire, Gabby, Jacob, and Stefano PHI 421 Introduction The Organization of the American Healthcare System US Healthcare System ● ● ● ● Healthcare in the United States is drastically different from many other healthcare systems around the world. Leading Healthcare Spenders: ○ Spending $4.5 trillion in 2022, making up almost 17.3% of the nation's GDP. The US healthcare system does not provide universal coverage and can be defined as a mixed system, ○ Gov. health coverage coexists with Privately financed market coverage. US: One of the most complex healthcare systems in the world ○ Multiple Intertwining Relationships: ■ Providers ■ Payers ■ Patients Constantly Evolving System: On average, payments for healthcare services typically exceed the hospital's cost of providing the underlying services. Organization of US Healthcare System ● ● ● Local levels of organizations: ○ Private healthcare providers ○ Clinics ○ Urgent Care Centers ○ Hospitals. These businesses are free to open or close according to the community resources, preferences, and the dictates of an “open market for hospital services.” ○ Patients can freely choose which hospital, physician, or clinic to receive care from. Hospitals compete for business based on factors like: ○ Price ○ Quality ○ Conveniences ○ Reputation. Hospitals are not restricted by regulations or limited to a specific patient pool, enabling them to actively compete for customers. Flow of Funds in US Healthcare Payments ● ● ● ● How patients pay for the care they're receiving is typically done by a combination of methods including private insurance, medicare, and medicaid. Healthcare systems receive payments from: ○ public institutions: government resources medicare and medicaid ○ private institutions: insurance groups Insurance can be covered by: ○ Employer: group insurance ○ Private insurance: nongroup insurance ○ Medicaid: designed for low income individuals and families, government provided ○ Medicare: based on age and physical condition, government provided Out-of-pocket payments and market provision of coverage predominate as a means of financing and providing healthcare. Payments Specifics ● Hospitals receive payment from both public and private financing sources Medicare pays the hospital a fixed amount based on the DGR, regardless of actual cost of treatment. Private insurance pays hospitals based on DRGs, case rates, per diems, fee-for-service, and/or discounted fee-for-service schemes. ● Inpatient Producers Paid through: DRG (diagnostic related group) for inpatient procedure medicare. ○ DRG assigns a set payment for a particular condition or treatment sequences; commonly used as the main payment scheme for hospitals. This payment cover accommodation, procedure, support staff, and drug/medical device cost. ● Outpatient Procedures: APC (ambulatory payment classification) codes are used by healthcare systems for billing and reimbursement. ○ APC represent a fee-for-service style of billing rather than the capitation, cost-based style of DRGs. Physician and other clinical fees are not included with DRG or APC codes ● CTP (current procedural terminology, used in both in & outpatient settings) codes are used and billed under the name of the provider. Key Elements & Evidence ● ● 90.37% 1.925% 7.7% 92.3% ● ● ● Structure: Mixed systems with private insurance, government programs (Medicare, Medicaid), and out-of-pocket payments. The coverage varies widely, and healthcare is not a legally recognized right. High Costs: U.S. healthcare spending reached $7,100 and $13,500 in 2024. Administrative costs make up 34% of healthcare spending, with significant barriers for uninsured and low-income individuals. Access Gaps: 92.3% (316 million) of the American population is insured in 2024, with the uninsured rate of those not insured is 7.7% (26 million) of the American population. Strengths: Access to advanced technology, choice of providers, and supportive programs like Medicare. Weaknesses: High costs, financial barriers, inefficiency, and lower life expectancy compared to other developed nations. Model: Canadian System Benefit: Universal coverage, lower costs, public accountability, and preventive care focus. Challenges: Longer wait times for specialized care but greater equity and access overall. Evidence Conclusion Canada’s healthcare system aligns more closely with principles of justice and equity, providing universal access and minimizing financial barrier, thus promoting fair treatment for all citizens. In contrast, the U.S. system, while offering choice and advanced technology, creates significant inequalities, with uninsured individuals-especially children and low-income families-facing limited access to care. Ethically, the Canadian model supports a duty of care to all, whereas the U.S. model raises concerns about dispersed access, challenging the ethical commitment to healthcare. What are the issues in the U.S. healthcare system? Weaknesses In the healthcare system High Costs and Inefficiency Fragmented and complex system Limited access and unequal care High costs and inefficiency Rising Out-of- Pocket Costs High premiums, deductibles, and co-pays making it difficult for many to afford necessary care, even with insurance. The U.S. family spends over $22,000 annually on healthcare. Administrative Overhead The U.S. healthcare system has some of the highest administrative costs globally, driven by complex billing systems, multiple insurance providers, and lack of standardization. U.S. healthcare administration costs are about 8% of total spending, compared to 1-2% in other developed countries. Expensive Prescription Drugs Americans pay some of the highest prices for prescription medications, exacerbating healthcare costs. The price of insulin has risen dramatically, leading to public outcry and calls for reform. Limited access and unequal care Geographic Disparities Rural and underserved urban areas often face shortages of medical professionals, leading to limited access to quality healthcare. Many rural hospitals have closed in recent years, leaving millions without easy access to care. Insurance gaps While the Affordable Care Act reduced the number of uninsured, millions still lack coverage due to gaps in Medicaid eligibility or unaffordable premiums. An estimated 27 million Americans remain uninsured as of 2023. Health inequities Racial and socioeconomic factors create disparities in access to healthcare, resulting in poorer health outcomes for certain groups. Black Americans are 30% more likely to die from preventable conditions like heart disease than white Americans. Fragmented and complex system Multiple Insurers and Plans The U.S. has a complex mix of private insurers, government programs (Medicare, Medicaid), and employer-based plans. This makes navigating care and insurance options difficult for consumers. Patients with multiple health issues may have different providers, creating fragmented care and communication challenges. Lack of coordination The complexity of the system leads to inefficiencies such as unnecessary tests, redundant procedures, and poor continuity of care. Patients seeing multiple specialists may experience lack of coordination, leading to missed diagnoses or conflicting treatments. Administrative waste Excessive paperwork, billing disputes, and insurance company denials waste time and money. Providers spend significant time dealing with insurance claims instead of focusing on patient care, raising costs across the system. How could we fix these issues? Resolving Issues in U.S. Health Care While there is no great way of fixing the United States Health care without backlash from any citizens, there are some steps that could fix the main problems with the system. 01 02 Provider Compensation Regulation of Drugs Provider Compensation How does the way some providers get paid impact Patients? United STATES HEALTH CARE currently ● ● ● Currently, some providers get paid per operation. this increases the amount of operations that the Dr. will do in order to meet self set financial goals or organizations goals. This causes problems to arise, for example, Unnecessary and unsafe operations. A change in compensation from quantity to quality care could change decrease the average cost for patients Post Change ● Decrease in potential healthcare cost for patients and overall safer operations for the betterment of patient’s health and not for the greed of the healthcare system. Government Regulation of Pharmaceutical Drugs What does the government Regulate the Prices of? The Government Currently regulates the prices of many essential goods in America. ● For example: Oil, Food, Electricity, Rent, etc. ● Many people consider these to be essential to life and comfortable living in America, so why are drug cost not regulated? What would Regulation Solve? ● ● Just like oil and electricity regulation would control the amount pharmaceutical companies could charge for certain products This limit would drive cost down for the average person and allow more people to access better healthcare. Is Healthcare A Basic Human Right? Our group believes that healthcare is a basic human right. This is due to the negative effects of high costs as well as improved health conditions of people with access to universal healthcare. As of 2024, approximately half of the world’s countries have a form of universal healthcare. Percent of GDP Spent on Healthcare 17% United States 8-12% Countries with Universal Healthcare Why should Universal Healthcare be considered? Lower High Costs Due to high costs, around 8% of Americans do not have health insurance and cannot afford basic healthcare. Lower Medical Bills In the United States, medical debt is the most common form of bankruptcy. Healthier Population Lower infant mortality rates, higher life expectancy, and better detection and monitoring of chronic diseases and illnesses are key characteristics in countries with universal healthcare. “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition...No one should get sick and die just because they are poor, or because they cannot access the health services they need.” -Dr. Tedros Adhanom Ghebreyesus (WHo Director-General) Conclusion Healthcare is a fundamental human right, while approximately half of the world's countries have implemented some form of universal healthcare, the United States remains an outlier, spending a disproportionate 17% share of its GDP on healthcare while still leaving millions without adequate access to essential services. It is clear that adopting universal health care could improve both the health and financial well-being of the nation, ensuring that no one is left behind due to their economic standing. RESOURCES ● ● ● De Lew, N, et al. “A Layman’s Guide to the U.S. HealthCare System.” Health Care Financing Review, U.S. National Library of Medicine, 1992, pmc.ncbi.nlm.nih.gov/articles/PMC4193322/. Accessed 14 Nov. 2024 “US Healthcare System Overview-Background.” ISPOR.Org, www.ispor.org/heor-resources/more-heor-resources/us-healthcare-system-overview/us-healthcare-syste m-overview-background-page-1. Accessed 14 Nov. 2024. https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspectiv e-2022 https://www.healthaffairs.org/doi/10.1377/hlthaff.2024.00460#:~:text=In%20the%20Congressional%20 Budget%20Office%E2%80%99s%20projections%20of%20health,and%207.7%20percent%2C%20or% 2026%20million%2C%20are%20uninsured.