Many of us working in digital health space have not been schooled in the U.S. health care system terminology. Here is a basic, but indispensable, overview. For an in-depth study, you are referred to “Essentials of U.S. Health Care Systems” by Shi and Singh .
The basic types of systems of care delivery in the U.S. are managed care, integrated care, Veterans Health Administration, and underserved care. In these systems, the patient (i.e., the covered person, referred to as ‘enrollee’ or ‘member’) is not the primary ‘payer’ for the services received. Employers or the government foot the bill for the most part.
Managed care is the dominant system; it integrates, coordinates and prices health care delivery functions. The above figure, adapted from , illustrates the elements and construction of a managed care system. The managed care organization acts like an insurance company to the employer or government, with its ‘plan’ analogous to insurance policy. The ‘plan’ sets forth the benefits and costs of care for the enrollees. Enrollees often contribute to a fraction of the plan premium through their employer. They also are usually responsible for a fraction of the cost of the care received, referred to as ‘copay’. Plans usually prescribe a set of health care ‘providers’, collectively referred to as the ‘network’. Out-of-network providers are usually not part of the plan benefit or require higher copay by the patient.
In integrated systems, a provider organization has integrated and coordinates its own network, through which it delivers comprehensive health care services. A few examples of such systems are Mayo Clinic, Kaiser Permanente, Cleveland Clinic, and Geisinger Health System. In contrast to managed care, integrated systems are both the provider and the insurer. The Veterans Health Administration is an integrated system by the government for the benefit of active and retired military personnel. It is part of the Department of Veterans Affairs (VA) and the largest integrated health system in the U.S.
The underserved systems, usually supported by the government or charitable funds, provide health care services (through community health centers, for example) to the uninsured—usually from the disadvantaged groups and communities. Government insurance programs such as Medicare (for qualifying senior citizens), Medicaid (for qualifying low-income citizens), and State Children’s Health Insurance Program (for children of uninsured families) additionally support the underserved.
Table 1 summarizes the terminology associated with the types of care services that the aforementioned systems provide. Primary care is the domain of the primary care physicians and focuses on prevention, diagnostic, therapeutic, health education, counseling, and minor preventive surgery. Care by specialized physicians—usually referred to by the patient’s primary care physician—is noted as secondary care. Tertiary and quaternary are further specialized care services—referred to by the primary care physician or secondary care specialists.
In closing, medical device manufacturers and pharmaceutical companies are also important elements of the health care ecosystem. The former research, develop and commercialize the medical devices—often technology intensive—that aid in disease diagnosis, therapeutic procedures and monitoring needs. The latter are companies that research, develop and commercialize drugs (i.e., medicine). The medical device and pharmaceutical industries are highly regulated, in the U.S. by the Food and Drug Administration.
Table 1: Terminology associated with the different types of health care services
|Acute care – When a patient is treated for a brief but severe episode of illness, for the sequel of an accident or other trauma, or during recovery from surgery. |
|Long-term care – Medical, social, and personal care services on a recurring or continuing basis to persons with chronic physical or mental disorders. The care may be provided in environments ranging from institutions to private homes. Long-term care services usually include symptomatic treatment, maintenance, and rehabilitation for patients of all age groups. |
|Primary care – Initial medical care by a health care provider to a patient, especially as part of regular, ambulatory care, and sometimes followed by referral to other medical providers. |
|Preventive care – A pattern of nursing and medical care that focuses on disease prevention and health maintenance. It includes early diagnosis of disease, discovery and identification of people at risk of development of specific problems, counseling, and other necessary intervention to avert a health problem. Screening tests, health education, and immunization programs are common examples of preventive care. |
|Ambulatory surgeries – Surgery performed on a person who is admitted to and discharged from a hospital on the same day. |
|Emergency room – The section of a health care facility intended to provide rapid treatment for victims of sudden illness or trauma. |
|Urgent care – A category of walk-in clinic focused on the delivery of ambulatory care in a dedicated medical facility outside of a traditional emergency room. |
|Pharmacy – 1. The branch of the health sciences dealing with the preparation, dispensing, and proper utilization of drugs. 2. A place where drugs are compounded or dispensed. |
|Home care – A health service provided in the patient’s place of residence for the purpose of promoting, maintaining, or restoring health, or minimizing the effects of illness and disability. Service may include such elements as medical, dental, and nursing care; speech and physical therapy; homemaking services of a home health aide; and provision of transportation. |
|Laboratory – A facility that provides controlled conditions in which scientific or technological research, experiments, and measurement may be performed. |
|Clinical laboratory – A laboratory where tests are done on clinical specimens in order to get information about the health of a patient as pertaining to the diagnosis, treatment, and prevention of disease. |
|Diagnostic – The art or act of identifying a disease from its signs and symptoms. |
|Therapy – The treatment of illness or disability. |
- L. Shi and D. Singh, Essentials of U.S. Health Care Systems, Jones and Bartlett Learning, 5th Edition, 2019.
- http://medical-dictionary.thefreedictionary.com (Accessed July 28, 2020)
- http://en.wikipedia.org/wiki/Urgent care (Accessed July 28, 2020)
- http://en.wikipedia.org/wiki/Laboratory(Accessed July 28, 2020)
- http://en.wikipedia.org/wiki/Clinical_laboratory (Accessed July 28, 2020)