The US Healthcare Systemand the Roemer Model

Lecture 2Tracey Lynn Koehlmoos, PhD, MHA

HSCI 609 Comparative International Health Systems

Organization of the US Health Services System

• Ever shifting mix of public/government sector, private sector and voluntary services.

• 16% of GDP spent on health services (2005)

• The US government now:– Major payer for care: Medicare, Medicaid– Provider of healthcare for special populations like

Tricare, Indian Health Services, VA– Major supporter of education and training of

many types of care providers

Introduction to the Roemer Model

• Developed by Milton I. Roemer, MD, MPH• WHO, UCLA School of Public Health• Pioneer in international health systems

research• Roemer Model of Health Services System

(1984) allows for clear understanding of health systems

Clear understanding = Meaningful comparisons

DELIVERYOF

SERVICES

ORGANIZATION OF

PROGRAMS

MANAGEMENT

ECONOMICSUPPORT

RESOURCEPRODUCTION

Roemer Model

Five Parts to the Model

• Organization of the Program

• Management of Health Services System

• Economic Support of Health Services

• Production of Health Services Resources

• Delivery of Health Services

Part 1: Organization

• Ministry of Health—all levels

• Other Public Agencies

• Voluntary Agencies

• Enterprises

• Private Market

Part 2: Management

• Planning

• Administration

• Regulation

• Legislation

Part 3: Economic Support

• Personal Households

• Charity

• Insurance (voluntary)

• Social Security

• Governmental

• Revenues

• Foreign Aid

Part 4: Production of Resources

• Manpower

• Facilities

• Commodities (drugs, DME, equipment, etc.)

• Knowledge

Part 5: Delivery of Services

• Primary Care—Prevention

• Primary Care—Treatment

• Secondary Medical Care

• Tertiary Medical Care

• Care of Special Disorders and Populations

Applying Roemer at Home

• Part I: Organization of Health Services:

• US health system is DECENTRALIZED

• Department of Health and Human Services (DHHS) instead of MoH

• DHHS regulates and finances many health services

• Services delivery primarily occurs in private sector

Part I: Organization

• Public Health at the national level

• Centers for Disease Control and Prevention

• Food and Drug Administration

• Centers for Medicare and Medicaid

• National Institutes of Health

• Agency for Healthcare Research and Quality

Part I: Organization

• Voluntary Agencies • Gap fillers

– Disease or interest group specificACS, ARC, AARP

– Professional associationsAPHA, AHA, AMA

– Philanthropic and religious organizations Robert Wood Johnson

Part I: Organization

• Private Market

• Most health services provided in the private market

• Most health insurance provided in the private market

• Pharmaceuticals and supplies (developed and sold)

• Health professional training

Part 2: Management

• Planning: No centralized national-level planning authority

• Administration: More applied in nature at project or program level

• Legislation: all government units have authority to enact laws (budgeting process, restriction and limitations, new programs

• Regulation: Implementation of laws, licensure, certification, accreditation

Part 3: Economic Support• Private Health Insurance (voluntary and

employment related) largest source of funds (34%) to US health services

• ~70% of <65 have some type of health insurance

• Household/Out of Pocket: 15%• Medicare: 17%• Medicaid: 16%

• $1.3 trillion in 2000• 16% of GDP in 2005

Part 3: Economic Support• Where does the money go?

• 33% hospitals (50% of this from Fed.)

• 23% physician services

• 10% drugs

• 9% other personal care

• 7% nursing homes

• 6% program administration

• 3% research and construction

• 2% home health care

Part 4: Production of Resources

• Manpower: Health Services Industry– Largest Industry in US: 11.9 million workers– 800,000+ physicians

• 270.6 per 100,000 population• 2:1 Specialist to Generalist practitioners • Medicare subsidized training (GME/residencies)

– 2 million+ nurses: shortage, training variations– Pharmacists, dentists, RT, OT, PT– Health Administrators

Part 4: Production of Resources

• Hospitals: – Various categories (I, II, III) & structures– Merge and integrate to expand scope– Financial challenges, cost shifting – Prospective Payment, negotiated rates

• Biomedical Research and Technology:– US most advanced on planet/ cost driver– Drugs developed in private sector/FDA approval– Most research publicly funded (via NIH)– No clear chain of dissemination/assessment

Part 5: Delivery Systems

Continuum of Care• Prevention and Promotion: Public Sector• Early Detection: Public and Private• Primary Care: Private sector; PCP• Secondary Care: Specialists/hospitals• Tertiary Care: Academic Health Center• Long Term Care: Medicaid is big payer• Palliative Care: Home or Hospice Medicare $ for

80%• Outside the continuum: chronic mental illness

DELIVERYOF

SERVICES

ORGANIZATION OF

PROGRAMS

MANAGEMENT

ECONOMICSUPPORT

RESOURCEPRODUCTION

Roemer Model

Conclusion

• Applying the Roemer Model to the US Healthcare System gives us a means to understand the system and make meaningful and direct comparisons.

• Skyrocketing costs, an aging population & a high percent of uninsured are issues of concern

• Quality-Access-Cost remain the overarching values of concern for the US healthcare system