Health Care Delivery

Health care delivery encompasses a complex system in which local, state, national, and international communities provide services that enable people to achieve a level of health at which they are able to live socially and economically productive lives. ‘Health for All by the Year 2000’ was adopted as policy by the World Health Organization (WHO) in 1981; however, variable levels of achievement of this mandate have actually been implemented to date. This entry provides a general description of the present health care delivery system in the United States as well as a brief historical perspective designed to provide a framework for the analysis of future trends, values, and needs related to health.

The United States has a very complex system, often called a ‘multiplicity of health care systems (or subsystems),’ and is currently experiencing significant changes. The health care delivery system of today has undergone tremendous change, even over the relatively short period of the past decade. New and emerging technologies, including drugs, devices, procedures, tests, and imaging machinery, have changed patterns of care and sites where care is provided. [Page 467]Quite realistically, the present system of health care delivery continues in transition, and the next decade promises even more change with a final product that looks very different than common delivery models used today.

In the United States, there are two basic sources of health care services: the private sector and the public sector. Traditionally, the private sector health care refers to arrangements in which an individual client contracts directly with an independent contractor to provide individual care on a fee-for-service basis. In contrast, health care provided through the public sector is usually funded by public taxes and provides health-related services for the protection of all citizens regardless of ability to pay; typically, the service provider bills the government or voluntary agencies. In both settings, the primary care provider could be a physician, physician's assistant, or advanced practice nurse who is trained, is licensed, and operates within professional ethics. Reimbursement is expanding for other types of specialized health care providers such as dentists, physical and massage therapists, mental health professionals, and numerous others.

Health care may be delivered in numerous settings, from inpatient (hospital or extended-care facilities) to outpatient (ambulatory) settings. Ambulatory settings, defined as any setting where the individual is not a bed patient, include hospital-based ambulatory services such as clinics, walk-in and emergency services, hospital-sponsored group practices, and healthpromotion centers; freestanding urgent care, same-day surgery, emergency centers, and retail health clinics; health department clinics; neighborhood and community health centers; nursing centers; organized home care; community mental health centers; school and workplace health services; prison health services; and a private clinician's office.

Although the delivery of health care traditionally has been disease oriented, there is an increasing movement toward primary care delivered in a ‘medical home’ model. The National Center of Medical Home Initiatives for Children With Special Needs, a group within the American Academy of Pediatrics, notes on its Web site that ‘a medical home is not a building, house, or hospital, but rather an approach to providing comprehensive primary care. A medical home is defined as primary care that is accessible, continuous, comprehensive, family-centered, coordinated, and culturally effective.’ Clinicians in the medical home model coordinate care between various subspecialists and are able to balance conflicting treatment issues. The care is delivered in settings close to where people live and work. The ultimate goal of this effort is to keep people as healthy as possible at a reasonable cost to the payer and to prevent disease.

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