Topics

• U.S. Healthcare Delivery System
• Strengths and Weaknesses
• Triple Aim
• References

NURS 410 - Health Care Delivery Systems & Informatics

Module 1: Overview of Healthcare Delivery System

U.S. Healthcare Delivery System

What is the definition of a system? A system is defined as:

• a regularly interacting or interdependent group of items forming a unified whole (numbering system or organizational system);
• a group of interacting bodies under the influence of related forces (gravitational system) and,
• a form of social, economic, or political organizations or practices (the capitalist system).(Merriam-Webster, 2015)

Identifying key words help us begin our discussions on the definition, components, and unique aspects of the U. S. health care delivery system. Nurses are the single largest component of an acute care or hospital staff and are the largest group of health care professionals (American Association of Colleges of Nursing, 2015). Nurses need to be conversant concerning the U. S. healthcare delivery system because nurses are:

• Providers of care;
• Designers of care;
• Coordinators of care and,
• Evaluators of care across the continuum.

The healthcare reimbursement system is an extremely complex framework of obtaining payment for services. One of the most problematic issues is that the “rules” governing healthcare reimbursement change frequently, with government payers sometimes changing on a day-to-day basis. Health insurance payers have a variety of healthcare reimbursement plans, and carry contracts with individual practices and health systems (contracts that are periodically renegotiated, which is just one source of change within the system). This means that there can be one price for services that occur within a health care system that’s contracted with a payer and another price for services that occur outside that system.

That’s confusing enough. But the phrase “the amount owed by the patient” refers to yet another level of complexity in the healthcare reimbursement system, regarding the determination of which party is responsible for what portion of the amount charged for a service. How much is the responsibility of the patient? How much is the responsibility of the insurer? This can come down to the particular plan for which the individual, or the company the individual works for, has contracted with the payer. This complexity can make it very difficult for practices to understand payer rules, keep up with changes to those rules, and stay ahead in the fast-moving healthcare reimbursement world.

Watch and listen to the short video titled Intro to Health Care (11:07 minutes) by the Brookings Institute which offers an explanation through the eyes of a patient! (https://www.youtube.com/watch?v=mG_BZ8GgqJU  ). Now consider answering the question, what makes the U. S. healthcare delivery system so complex?