Action. >> In this segment of the lecture, we will review the third World Health Organization building block, that is, service delivery. The World Health Organization defines service delivery as, in any health system, good health services are those which deliver effective, safe, good quality personal and non-personal care to those that need it, when needed, with a minimum of waste. Services, including prevention, treatment, or rehabilitation, may be delivered in the home, community, the workplace, or in health facilities. Here I want to just focus on a couple of elements of that definition of quality, that is, that services are provided to those that need it. And this is relevant in particular for the uninsured part of the population, which do not have access to care by way of the insurance system. The second is services when they are needed. This is important because one of the great difficulties in every health system is in ensuring that populations of people receive the best or recommended care in a timely fashion. It is surprising in all healthcare systems that relatively large proportions of people in any given population do not receive best or recommended care. The third is that care is delivered with a minimum of waste, which can be described as efficiency. Here we are concerned with ensuring that patients receive only the care that they need, and they do not receive unnecessary care. In addition, even where patients receive needed care and do not receive unnecessary care, the high cost of these services may amount to a form of waste. The most important part of the service delivery building block is reflected in this slide. In this rather complex diagram of the US health system, at the top of the diagram is the system of financing, public financing and private financing. It's easy to overlook the significance of financing being at the top of this diagram. In other high income countries, the body that is at the top will be the government or one of the legislative bodies, which determines the framework for the healthcare system as a whole. In between the financing in this diagram, right down to the box just below the bottom of the diagram, which is service delivery, there are a number of regulatory functions that govern the delivery of and payment for health services. But the most significant one is the box towards the bottom, which is service delivery. That's significant because in a polycentric system of healthcare with many insurance systems, it is healthcare providers who are the integrators of the system. Healthcare providers, including doctors, hospitals, outpatient clinics, are the ones that integrate various forms of regulation and various forms of payment to ensure that particular categories of patients receive good quality healthcare without incurring an unreasonable level of out-of-pocket payments. This imposes great costs and burdens on service delivery providers, and is one of the important features of complexity and polycentricity in the US health system. That process of integration by the service delivery building blocks arises in the following way. Doctors, and hospitals, and other outpatient providers of healthcare services form networks. Those networks contract with particular insurers. And it is those contracts between networks or providers and insurers which then determine the availability of services to the people covered by those particular forms of insurance. It is also those arrangements which determine the level of copayments and deductibles. This slide is a comparative analysis of the amount of spending on hospitals, and physicians, and prescription drugs. In this segment of the lecture, I want to focus on spending on hospitals and physicians. The US, in this diagram, is the second from the bottom. The expenditure on hospitals is below the OECD, at around 34% of total expenditure. The expenditure on physicians and medical practice is well above the OECD median, at 16.9% of total health expenditure. This is nearly double the OECD median expenditure on doctors and medical practice. This is significant because, as we'll see later, there are actually less doctors per capita in the United States. And on average, there are less visits to the doctor per capita in the United States. These payments and the extent of the spending on doctors in the United States reflect the central role of doctors in the US health system. The central role of doctors and the complex sets of arrangements that emerge between doctors and hospitals is another element that adds to the complexity and polycentricity of the US health system. The following slide indicates some aspects of utilization in the United States. The first slide reflects the numbers of acute care hospital beds. What's significant about this graph is the United States has 2.5 acute care hospital beds per 1,000 of population, which is significantly less than other high income European countries. And well below the OECD median of 3.3 beds per 1,000 of population. This is a measure of structural capacity, but the US also has lower levels of usage of hospital beds. One measure of usage is a measure of hospital discharges. The United States has approximately 125.5 hospital discharges per 1,000 of population, which is well below the OECD median of 156. The number of hospital discharges in the United States is well below that of the United Kingdom. This is significant because the National Health Service in the United Kingdom consumes significantly less resources than the US health system. And because there are very specific efforts to make best use of the hospital stays in the National Health Service. The next slide is in relation to doctor consultations per capita. This is an important measure that illuminates usage of healthcare services in the United States. In the United States in 2016, there were 4 consultations with a doctor per capita. By contrast, in 2016 in the United Kingdom, that figure was 5. But in Germany, which we'll review in the next module, that figure was 10 consultations per capita. These two slides reflect something important about patterns of utilization, which is that patterns of utilization, what I would call ordinary, basic medical care, are somewhat below the OECD median. And are below many other high income countries. However, when we come to the number of high cost, high technology interventions, we'll see that the rate of utilization in the United States is higher than the OECD median. In this graph referring to the numbers of hip replacements, the figure in the United States was second only to Switzerland. This reflects the usage of high technology services in the US. It would be possible to provide a graph for other high technology services, which would show a similar pattern. For example, the numbers of MRIs conducted per capita in the United States follow a similar pattern. It's important then to reflect on some of the strengths of the US health system. One of those is in relation to preventive care. This graph is referring to flu immunizations, which is an important indicator of preventive care. The US has a very high rate of flu immunizations in comparison to other high income countries, with 69% of people over the age of 65 being immunized in 2016. This is reflected across the board for other forms of preventive care. In summary, what we're left with in the United States is that even though United States spends a very large amount of money, that is, $10,000 per capita on healthcare, the rates of utilization for many ordinary, basic services are somewhat below utilization in other high income countries. There is also less capacity or actual infrastructure to provide those services. However, the US does have very high rates of usage for high technology interventions, and it does have very high levels of usage for preventive care services. So the interaction between the service delivery and financing governance building blocks produces an odd collocation of patterns. It is a high cost system. It does not cover the entire population. It does, on the whole, provide less services to the population as a whole who are covered by the insurance. But it does provide higher levels of high technology healthcare services.
