HMGT EXAM 3 REVIEW

Per 2019 Gallup Report

AMONG 36 OECD NATIONS,THE UNITED STATES RANKS: •28th in the life expectancy of its residents, •31st in infant mortality and •16th in heart attack mortality, but is •1st in the highest healthcare costs per person. US Healthcare Cost Crisis, Gallup, 2019 •Among younger adults ages 25-44, the death rate rose 21 percent for whites and blacks and 13 percent for Hispanics between 2012 and 2017. Most died of injuries such as drug overdoses, suicides, homicides and heavy use of alcohol. •Among middle-aged adults ages 45-64, death rates rose by 6.9 percent for whites and 4.2 percent for blacks. The Hispanic death rate in this cohort did not change significantly. •The analysis further illuminates negative health trends across the U.S., where the opioid epidemic and heart disease are decreasing life expectancy. CDC, July 2019

Chapter 12: Cost, Access, Quality Star:

Introduction •Three cornerstones of health care delivery -Cost -Access -Quality -Experience is emerging ... may be redefined now •Expansion of access will increase health care expenditures. •Costs of health care from a macro and micro perspective. •Equal access to high quality care. •Cost is important in the evaluation of quality. •Quality -Up-to-date capabilities, evidence-based processes, and measuring outcomes

Chapter 11: Health Services for Special Populations

Introduction: •Certain groups at greater risk of poor physical, psychological, or social health • Terms used -Underserved -Medically underserved -Medically disadvantaged -Underprivileged -American underclasses •Population groups -Racial and ethnic minorities -Uninsured children -Women -Rural area residents -Homeless population -Mentally and chronically ill -Disabled -HIV/AIDS

Quality of Care

In March 2001, the Institute of Medicine (IOM) issued: -Crossing the Quality Chasm, which identified "six aims of quality improvement": 1.Safety 2.Effectiveness 3.Patient-Centeredness 4.Timelines 5.Efficiency 6.Equity In March 2001, the Institute of Medicine (IOM) issued: Ten Simple Rules for Redesign: 1.Care based on continual healing relationships 2.Care customized by patient needs and values 3.Patient is the source of control 4.Knowledge is shared 5.Decisions are evidence based 6.Safety is a priority 7.Transparency is necessary 8.Needs are anticipated 9.Waste is continuously decreased - Lean Six Sigma 10.Cooperation among clinicians is a priority In March 2001, the Institute of Medicine (IOM) issued: Changes in structure and processes of the healthcare system: 1.Apply evidence to health care delivery 2.Using information technology 3.Aligning payment with quality improvement 4.Preparing the workforce

Chapter 13: Health Policy Star:

Introduction •Government involvement in social welfare. -Traced to almshouses and pesthouses •Social programs created under the Social Security legislation in the 1940s. •Started with Pres Truman •Medicare, Medicaid in 1965 •CHIP in 1967 •Government has had success bringing about social change through health policy.

Chapter 14: The Future of Health Services Delivery

Introduction •Is seeing the future harder now???? •Erosion of employer-based health insurance. •Main ACA beneficiaries were those who obtained Medicaid coverage. •Government-sponsored exchanges lowered some premium costs. •Adults under age 26 were added to their parents' health plans. •Future impact on economy, incomes, health

When did Obamacare start?

The timeline of key events leading up to the passage of the Obamacare law began in 2009. Here is a list of those events, along with key provisions that went into place after the law was enacted. •July 2009: Speaker of the House Nancy Pelosi and a group of Democrats from the House of Representatives reveal their plan for overhauling the health-care system. It's called H.R. 3962, the Affordable Health Care for America Act. •August 25, 2009: Massachusetts Senator Ted Kennedy, a leading supporter of health-care reform, dies and puts the Senate Democrats' 60-seat supermajority required to pass a piece of legislation at risk. •September 24, 2009: Democrat Paul Kirk is appointed interim senator from Massachusetts, which temporarily restores the Democrats' filibuster-proof 60th vote. •November 7, 2009: In the House of Representatives, 219 Democrats and one Republican vote for the Affordable Health Care for America Act, and 39 Democrats and 176 Republicans vote against it. •December 24, 2009: In the Senate, 60 Democrats vote for the Senate's version of the bill, called America's Healthy Future Act, whose lead author is senator Max Baucus of California. Thirty-nine Republicans vote against the bill, and one Republican senator, Jim Bunning, does not vote. •January 2010: In the Senate, Scott Brown, a Republican, wins the special election in Massachusetts to finish out the remaining term of US senator Ted Kennedy, a Democrat. Brown campaigned heavily against the health-care law and won an upset victory in a state that consistently votes in favor of the Democratic party. •In January 2010, eHealth published research conducted by Opinion Research highlighting public perceptions of health-care reform. •March 11, 2010: Now lacking the 60th vote needed to pass the bill, Senate Democrats decide to use budget reconciliation to get one bill approved by the House and the Senate. The use of budget reconciliation only requires 51 Senators to vote in favor of the bill for it to go to the president's desk for signature. •March 21, 2010: The Senate's version of the health-care plan is approved by the House in a 219-212 vote. All Republicans and 34 Democrats vote against the plan. •March 23, 2010: President Obama signs the Affordable Care Act into law.

How do we contain costs?Regulatory Approaches Star:

•All-payer (single-payer) system •ACA •Health Planning •Price Controls •Peer Review •New approach is transparency

Advisory Commission on Consumer Protection and Quality

• ". . . There is no guarantee that an individual will receive high-quality care for any particular health problem . . . overutilization of services, underutilization of services and errors in health care practice."

RAND Corporation Star:

•". . . serious and pervasive nature of quality-of-care problems."

Crossing the Quality Chasm

•"Four key aspects of the current context for health care delivery help explain the quality problems outlined above: the growing complexity of science and technology, the increase in chronic conditions, a poorly organized delivery system, and constraints on exploiting the revolution in information technology."

Mental Health

•1 in 4 Americans have a mental disorder in any given year •Industry plagued with disparities in availability and access -Hinges on financial status -Tear down the stigma, fear and the hopelessness •Medicaid is the single largest payer -States had strong emphasis on inpatient care •Barriers to mental health care •Uninsured and mental health •Insured and mental health •Managed care and mental health •Mental health professionals -See Table 11-7 •Depression is the most common illness among primary care patients; it affects approximately 14.8 million adults in the US. •Risk Factors -History of depression -Family history -Stressful life events -Lack of social support -History of anxiety -Postpartum period -Substance abuse -Medical comorbidity -Being single -Old age -Low socioeconomic status -Female gender •The plan: 1.Build science base 2.Overcome stigma 3.Improve public awareness 4.Ensure supply of mental health 5.Ensure state-of-the-are treatment 6.Tailor treatment to demographics 7.Facilitate treatment 8.Reduce financial barriers

To Err is Human: Building a Safer Health System

•30 publications - • •"These quality problems occur typically not because of a failure of goodwill, knowledge, effort, or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized"

Legislative Process

•A bill is introduced in the House of Representatives. •If approved it is forwarded to the Senate. •Sent to President after passing the House and Senate •If signed it becomes law.

The Homeless

•An estimated 3.5 million people are without a home -Single men - 43% -Single women - 17% -Children under 18 - 39% -Families with children - 33% •A multifaceted problem related to personal, social, and economic factors -Homeless adults and children have a high prevalence of untreated acute and chronic medical, mental health, and substance abuse problems -At a greater risk of assault and victimization -Exposure to harsh weather •Approximately 1 in 200 people became homeless in 2011. -Adult population is 63% men and 37% women. -Estimated 22.8% are children under age 18. -35.8% are families with children. -14% are veterans. •Shortage of adequate low-income housing. •Barriers to health care. •Barriers to Health Care -Barriers to ambulatory services -High hospitalization rates •Reasons for barriers: 1) Individual factors (e.g., competing needs, substance dependence, mental illness) 2) System factors (e.g. availability, cost, convenience) •Outreach to shelters, hotels, soup lines, parks, bus stations •Health Care for the Homeless -A federal effort for medical service -Robert Wood Johnson supported •Salvation Army provides: -Social, rehab, support, food, housing

Development of Legislative Health Policy Star:

•Aspects of the U.S. government and populace -Complex requires private and public involvement -Relationship of the government to the private sector -Distribution of authority and responsibility within a federal system of government -Relationship between policy formulation and implementation -A pluralistic ideology as the basis of politics -Incrementalism as the strategy for reform

Anthro-Cultural Factors

•Beliefs, values, ethos, and traditions espoused primarily by the middle class •Historically, these have acted as a strong deterrent to radical changes in health care •Disapproval of the ACA has increased among Americans •The American public could end up deciding the ACA's final fate •What effect did this have on the Pandemic Response?

Public Reporting of Quality

•CMS programs on quality -Initiatives to improve care provided to Medicaid and CHIP enrollees •AHRQ quality indicators -Prevention, inpatient, patient safety, and pediatric •States' public reporting of hospital quality

Introduction

•Certain groups at greater risk of poor physical, psychological, or social health • Terms used -Underserved -Medically underserved -Medically disadvantaged -Underprivileged -American underclasses •Population groups -Racial and ethnic minorities -Uninsured children -Women -Rural area residents -Homeless population -Mentally and chronically ill -Disabled -HIV/AIDS

Summary

•Challenges and barriers in accessing health care services for certain population groups. •Health needs of these population groups vary. •Gaps exist between population groups and the rest of the population.

Star: Chronically Ill

•Chronic diseases are the leading cause of death in the U.S. -Result in limitations on daily life activities. -Treatment accounts for 86% of U.S. health costs. •Disability -Categorized as mental, physical, or social -Disability tests

Migrant Workers

•Community and migrant health centers •Rural Health Clinics Act -Concern rural areas could not support a physician -Permitted PAs, NPs, and CNMs with rural clinics to practice without the direct supervision of a physician -Enabled rural health clinics to be reimbursed by Medicare and Medicaid

Policy Cycle Star:

•Comprising five components 1.Issue raising - fulfill a promise or solve a problem 2.Policy design - govt agencies or outside task forces 3.Public support building - bully pulpit; media; network 4.Legislative decision making and policy support building - depts working with congress 5.Legislative decision making and policy implementation

Legislative Committees and Subcommittees

•Congress has three important powers -Power to enact laws related to health policy -Power to tax to encourage or discourage behavior -Power to spend (allocate resources) in support of programs, states, agencies (CMS, NIH, etc)

How Did We Get Here?

•Cost •Total •Personal •Quality •Safety •Health •Access •Availability •Equity •Literacy •Experience •Simple •Patient/Customer Centered •Integrator

The Rural Health Clinics Act

•Created due to concerns that isolated rural communities could not generate revenue to support physician services •A reimbursement mechanism to create financial viability and ability to receive Medicare and Medicaid reimbursement •Midwives, Physician Assistants, Nurse Practitioners do not need physician oversight •There are over 3000 currently operating

The National Health Service Corps

•Created in 1970 •To recruit and retain physicians in shortage areas •A scholarship and loan repayment program -Targeted doctors, dentists, nurse practitioners, midwives, and mental health professionals who serve a minimum of two years in underserved areas. -Since 1972 over 27,000 have been placed in medically underserved communities.

How do we contain costs? Competitive Approaches Star:

•Demand-side Incentives •Supply-Side Regulation •Payer-Driven Price Competition •Utilization Controls •Competition •Rivalry among sellers for customers -Health care competition can be based on technology, quality, amenities, access

Medically Underserved Areas (MUA)

•Developed to support the -federal health maintenance organization grant program -community health center and rural health clinic programs •Factors in designing MUAs: -available health resources related to area size and population, health indices, care and demographics •The Index of Medical Underservice was developed comprising four variables: -Percent of population below poverty income levels -Percent of population 65 + years old -Infant mortality rate -Primary care physicians / 1,000 population

Global Threats and International Cooperation

•Disease and disability pose global challenges. •Air travel enables infectious diseases to spread. •International Health Regulations (IHR). •Wars and terrorism. •Emerging antibiotic resistance among infectious agents. •Biological warfare programs. •Health care to millions around the world.

Political Forces

•Education and immigration policies the number and qualifications of health care workforce •Americans remain divided on major policy issues, including health care •Politics also has an effect on the economy and taxes •So far, raising the debt ceiling rather than reducing spending has occupied US politicians

The ACA and the Economy

•Effect on employment and incomes is uncertain •Some evidence that employers are delaying or cutting hiring, and reducing worker hours to skirt the law's mandate •Part-time workers could get government subsidies to buy health insurance through the exchanges •However, the affordability of exchange-based plans is unclear

Forces of Future Change Star:

•Eight forces included in the framework 1.Social and demographic 2.Political 3.Economic 4.Technological 5.Informational 6.Ecological 7.Global 8.Anthro-cultural

Trends in National Health Expenditures Star:

•Evaluating national health care expenditures 1) Compared to Consumer Price Index (CPI) •CPI measures general inflation in the economy and calculates the annual changes (See Figure 12-2) 2) Compared to Gross Domestic Product (GDP) •See Figure 12-3

Health Care Delivery Infrastructure of the Future

•Focus on Public Health! •Toward population health -Accountable care communities -Vermont blueprint •Patient activation •Future workforce challenges -Nursing profession -Primary care physicians -Training in geriatrics

Informational Forces

•Garnering IT's potential for health care delivery and management of health care organizations will continue well into the future •Smart cards ... •Challenge today with Information, privacy, freedom, and public health requirements ...

New Technology

•Genetic mapping: -Genometrics - identifying genes with specific disease traits -Prevention and gene therapy (molecular medicine) - cancer treatment is a prime candidate •Personalized medicine and pharmacogenomics: -Pharmacogenomics - how genes affect a person's response to drugs -Specific gene variations will be matched to individual patient responses to medications •Drug design and delivery: -Multidisciplinary advances will shorten drug discovery time -Rational drug design at the molecular level will also reduce labor cost and lab expenses -New drug delivery systems (e.g., cellular uptake of nanoparticles) will improve drug delivery to targeted sites and improve drug effectiveness •Imaging technologies: -Research in four areas: •new energy sources that minimize damage •finer detection of abnormalities •3D technology •higher resolution displays -Increased emphasis on the brain for medical interventions -Applications in pain management, minor strokes, and Alzheimer's •Minimally invasive surgery: -cost efficiency and improved quality of life •Vaccines: -Therapeutic use in noninfectious diseases, such as cancer -New vaccines for emerging infections -Safer vaccines for widespread use, for example, against bioterrorism Expectation is Immediate •Blood substitutes: -Necessary when supplies of real blood fall short •Xenotransplantation: -to overcome the shortage of transplantable tissue •Regenerative medicine: -Repair damaged tissues and organs -Both in vivo and in vitro -Cure for virtually any disease: diabetes, heart disease, renal failure, osteoporosis, etc.

New Frontiers in Clinical Technology

•Genetic medicine •Rational drug design •Targeted drug delivery •Imaging technologies •Minimally invasive surgery •Vaccines •Immunotherapy •Blood substitutes •Xenotransplantation -3D bioprinting •Regenerative medicine

Global Forces

•Globalization intensifies cross-national cultural, economic, political, social, and technological interactions - health and health care will be affected in diverse ways through multiple pathways •Example: cross cultural factors affect the effectiveness of professionals that are part of "brain drains" or "brain gains" •Some signs of increasing globalization: -Drugs manufactured in Asia are exported to western nations -Medical tourism -Cross-border telemedicine -Desire of foreign hospitals and clinics to move into the US -Infection? Tourism impact on pandemic? -Medical capability dependency? Pharma, Tech, PPE?

Principal Features of U.S. Health Policy

•Government as subsidiary to the private sector -Not a right of citizens in the US - PS is dominant -Is healthcare a right? Or health a right? -Mistrust of government basis of Constitution -"the market" is blamed - incremental adjustments -Managed Care limits and Medicare Advantage -Public health, environmental protection, disease control and preparedness/bioterrorism Star: •Fragmented policies -Checks and balances limit authority -Little coordination of federal, state and local government policies -Complexities of private vs public systems -Fragmented financing •Employed - elderly - poor - special populations •Congress •Incremental and piecemeal policies -Result of compromises from competing interests -Ex: inclusions in Medicaid for additional coverage of children and women based on FPL -Medicare with additional benefits, HMOs, hospice and some younger people •Interest groups as demanders of policy •The powerful groups have resisted any major changes to the existing healthcare system •All about protecting their own interests •AMA, AHA, PhRMA, AARP (supported ACA), •Physician interests are fragmented •Labor unions, Education, Pharma/tech -Tech contributes to rising costs/provides health benefits and jobs •Likely to remain important influencers in US policies - Maybe will change? •Investment in cost saving alternatives - Value •Business is a major influencer as well -Large and small in regard to required insurance -Workplace health and safety •Some represent consumer interests, but influenced by congress and media coverage •Pluralistic suppliers of policy -All Branches and levels can establish policy -President and Congress most influential -Opposition brings challenges and transparency •Decentralized role of the states -Major role in healthcare policies by state autonomy -Insurance, licensure, Medicaid, public health, CHIP -Perception of "closer to the need" - now challenged with Pandemic •Impact of presidential leadership -Significant in implementing policy change -Ex: Obama with ACA and industry compromise -Truman with Hill-Burton -Johnson with Medicare and Medicaid -Reagan with PPS -Nixon with HMO -Clinton with HIPAA -Bush with Part D -Trump with transparency and now COVID-19 Star: •Politics of the ACA -Obama stated everyone would have health insurance. -ACA became reality following a unique set of political circumstances -Speed with which the reform was pushed through the legislative process -General public was confused and not supportive about the legislation

Key Issues:

•Growing Complexity of Science and Technology •Increase in Chronic Conditions •Poorly Organized Delivery System •Constraints on Exploiting the Revolution in Information Technology

Summary of IOM Report

•Health care is plagued today by a serious quality gap. The current health care delivery system is not robust enough to apply medical knowledge and technology consistently in ways that are safe, effective, patient-centered, timely, efficient and equitable. . . We must build a 21st century health care system that is more equitable and meets the needs of all Americans without regard to race, ethnicity, place or residence, or socioeconomic status. . .

Reasons for Cost Escalation Star:

•Medical cost inflation influenced by: -PRICING -Growth of technology -Third party payment -Imperfect market -Increase in elderly population -Medical model of health care delivery -Multipayer system, administrative costs -Defensive medicine -Waste and abuse -Practice variations

Children

•Health insurance is a major determinant of access to and utilization of health care. •Coverage rates vary across races and ethnicities. •Unintentional injuries are the leading cause of death for children and adolescents. •Asthma is a common childhood chronic disease. •Depression has an impact on adolescent development. •Children's health has certain unique aspects. -Developmental vulnerability and dependency •Health care for children is patchwork, disconnected programs •38% covered under Medicaid, 54% covered under private insurance •Developmental Vulnerability: the rapid and cumulative physical and emotional changes that characterize childhood, and the potential impact that illness, injury, or disruptive family and social circumstances can have on a child's life course trajectory. •Dependency: children's circumstances that require adults to take responsibility for recognizing and responding to their health needs. •New morbidities, e.g. drug, alcohol abuse, violence, emotional disorders, learning problems

Different Forms of Health Policy Star:

•Health policies -a by-product of public social policies -pertains to health care at all levels, including policies affecting the production, provision, and financing of health care services. •Health policies can be made through the private sector or the public policymaking process •Different forms of health policies -Affect groups or classes of individuals -Physicians, the poor, the elderly, and children -CON to limit and manage capital investment •Health policies emerge as by products of social policy - Ex Social Security Act of 1935 •Collective bargaining increased employer ins •Tech grew from policy support of biomed research •Patent law policy encouraged private interests •Limited by the political and economic system •Pro individual and pro market creates incrementalism •Generally policies are based on the notion of local communities are best positioned to develop policy for their own needs ... however they are bound by state and federal policies and regulations •Public Health policies include: 1.Reforms in medical education 2.1965 enactment of Medicare and Medicaid 3.Federal funding for family planning clinics 4.A merger of two hospitals violates antitrust laws 5.Procedures for licensing physicians 6.Monitoring sanitation standards in restaurants 7.Banning smoking in public places

Summary

•Health policies are developed to serve the public's interests. •Interest group politics have an influence on policy. •Presidential leadership and party politics played a major role in the ACA passage. •Critical policy issues pertaining to access, cost, and quality remain unresolved.

Comparative Effectiveness Research

•How well a chosen intervention would work compared to other available treatments •To assist in making informed decisions to improve health care for individuals and populations •The goal is to improve outcomes and reduce waste •The ACA has established a Patient-Centered Outcomes Research Institute: -To enable patients and caregivers collaboratively assess the value of health care options -The big question: Will the government's efforts improve people's health and save money?

Quality of Care Star:

•IOM's quality implications -Quality performance has a range from unacceptable to excellent. -Focuses on services provided by the health care delivery system. -Quality may be evaluated from the perspective of individuals and populations or communities. -Emphasis on desired health outcomes. Dimensions of quality •Microview -Clinical (technical) aspects -Interpersonal aspects -Quality of life •General HRQL •Disease-specific HRQL •Institution-related quality of life •Macroview -Mortality -Incidence and prevalence

Racial/Ethnic Minorities: Asian Americans

•In 2015, Asians accounted for only 5.6% of the U.S. population. •Asian Americans constitute one of the fastest-growing U.S. population segments.

Racial/Ethnic Minorities: American Indians and Alaska Natives

•Incidence and prevalence of certain diseases in the AIAN population are a prime concern. •Higher death rates from alcoholism, tuberculosis, diabetes, injuries, suicide, and homicide. •Indian Health Care Improvement Act. •Indian Health Service.

Summary

•Increasing costs, lack of access, and quality concerns pose the greatest challenges. •Lack of universal coverage negatively affects the health status of uninsured groups. •Access to medical care is one of the key determinants of health status. •Health care quality at the micro and macro levels.

Three Major Reports - 1998 Star:

•Institute of Medicine's National Roundtable on Health Care Quality •Advisory Commission on Consumer Protection and Quality •Literature search by the RAND Corporation

Affordable Care Act and Access to Care

•Insurance coverage and access to health care have increased. •Fewer report problems with medical bills and financial barriers. •Gaps in access to and affordability of care. •Preventive services without cost sharing expanded.

Access to Care

•Key implications of access for health and health care delivery -Access to medical care, along with environment, lifestyle, and heredity factors. -Access is a benchmark in assessing the effectiveness of the delivery system. -Measures of access reflect if delivery is equitable. -Access is linked to quality of care and efficient use. •Framework of access •Five dimensions of access -Availability -Accessibility -Accommodation -Affordability -Acceptability

Racial Ethnic Minorities Stats

•Low birth weight is most common among Black Americans •White adults drink more alcohol compared to other racial/ethnic groups •Mammography use of women 40+ years old is: -greatest among white females, -lowest in Hispanics

Ecological Forces

•Major implications for public health -New diseases - COVID-19 -Natural disasters -Bioterrorism - New threats are real -Zoonoses - from animal to human •World population growth will intensify human-animal-ecosystems interface engendering new diseases •Technology will find new applications in public health and safety •Dealing with public health threats also divert resources from routine health care •Global interaction is threat to health and economy??

Mental Disorders

•Managed care -Managed care is also expanding into mental health -State and local government want to contract with managed care organizations to handle the mental health and substance abuse services covered by Medicaid.

Measurement and Current Status of Access

•Measurement of access -Using conceptual models access is measured at three levels 1.Individual 2.Health plan 3.Delivery system •Current status of access

Cost Containment under Health Reform

•Medicare payment cuts to providers. •New taxes imposed. •Reforms contributed to a health care spending slowdown. -Tightening provider payment rates -Providing incentives to reduce costs •Medicare projected to spend $1 trillion less by 2020.

Critical Policy Issues Star:

•Most health initiatives focused on access, cost, and quality of care. •Health disparities and social policies •Access to care - right to all care or basic care? -Providers - planning and community health centers -Integrated access - primary - acute - long term -Access and the elderly - funding - chronic - long term -Access and minorities - ACA and IHS -Access in rural areas - tech vs phy vs outreach -Access and low income - Medicaid and CHIP -Access and persons with HIV/AIDS •Cost of care -Increasing drug prices have drawn public attention. -No government action taken to prevent price hiking -Prices of prescription drugs may continue to rise. -Technology -Pandemic -Future impact on cost?? •Quality of care -Six areas of quality improvement 1.Safety 2.Effectiveness 3.Patient centeredness 4.Timeliness 5.Efficiency 6.Equity •Quality of care (continued) -Research on quality -Malpractice reform - national database, limitation of awards, defensive medicine, etc •Role of research in policy development -Documentation -Analysis -Prescription •Future considerations in health policy -Domestic health policy •Initiatives to expand and evaluate primary care delivery models •Expect review of public policy based on pandemic lessons learned -International health policy •Government spending on global health initiatives is stable. •New focus ... WHO funding? More accountability for results -Public Health ... Pandemic Lessons???

Most Influential Committees

•Most influential House committees -Ways and Means Committee -Commerce Committee -Committee on Appropriations •Most influential Senate committees -Committee on Labor and Human Resources -Committee on Finance

Rural Health

•National Health Service Corps •Health professional shortage areas -Health Professions Educational Assistance Act -Three types of HPSAs by geographic areas, population groups, and medical facilities •Medically underserved areas -Percentage of population below poverty income levels -Percentage of population 65 years of age and older -Infant mortality rates -Number of primary care practitioners per 1,000 population •Poor access due to: -poverty, long distances, topography, weather, availability of health care and transportation •Measures to improve rural health care: 1) The National Health Service Corps 2) Health Manpower Shortage Areas 3) Medically Underserved Areas 4) Community and Migrant Health Centers 5) The Rural Health Clinics Act 6) Rural Managed Care

Economic Forces

•National debt - spending cuts, tax increases, and economic growth will be needed •Economic growth - growth has been slow; growing dependency on government handouts does not bode well •Employment and household income: incomes has fallen •National health expenditures are expected to consume almost 20% of GDP in 2022 •A golden prospect: The US is now the world's largest energy producers - but, much will depend on future energy policy •Preparedness by universities for today's job market •Bringing back jobs •Domestic energy •ACA determination by courts and congress •Border Tax •Tax cuts and renewed US investment •Less regulation •Market transparency of costs and pricing

Policy Implementation Star:

•New law is forwarded to the appropriate agency of the executive branch -Multiple levels interpret and implement legislation •Proposed regulations published in the Federal Register -Hearings on how law is to be implemented •Parties may adjourn to the courts •Ex: Tricare for Life legislation •Implementation of the ACA - 31 expanded Medicaid -Twelve states had decided to create state-based health insurance exchanges. -Five states opted for a state-based marketplace through the federal platform. -Six selected state-partnership marketplaces. -Twenty-eight states' health insurance exchanges were created by the federal government.

Future of Health Care Reform

•No single-payer system -Issues in establishing a single-payer plan -Renewed discussion based on Pandemic? -How? •Six Issues -Shift in costs from private to public -Overt rationing to manage demand -Disruption of est programs, Medicaid, Medicare -Govt would assume roles of insurer and finance -Opposition from insurance and providers -Not a primary function of govt per Constitution •Reforming the reform - Good vs Bad -Cost of insurance for businesses/individuals -Cost of health care services -Crossing state lines -Reduced administrative costs -High risk pools and adverse selection in ACA -Tort reform •Universal coverage and access -Give up the dream of "total, universal care for any ailment freely available on demand"

HIV/AIDS

•Number of AIDS cases reported -Increased between 1987 and 1993 -Decreased between 1994 and 1999 -Increased between 2000 and 2004 -Decreased since 2005 •HIV Infection in rural communities •HIV in children •HIV in women •HIV/AIDS-related issues -Need for research -Public health concerns -Discrimination -Provider training •Cost of HIV/AIDs - See Figure 11-12 •AIDS and the U.S. health care system -AIDS is characterized by a gradual decline in physical, cognitive, and emotional function. - As HIV disease progresses, many people become disabled and rely on public entitlements.

Women

•Office on Women's Health -Specific goals that span the spectrum of disease and disability •Women and the U.S. health care system -At a disadvantage in obtaining employer-based health insurance •The leading providers of care in the nursing profession -Also in allopathic and osteopathic medicine, dentistry, podiatry, and optometry (see Figure 11-9) •Women in the US live eight years longer than men, but they suffer greater morbidity and have poorer health outcomes. •Heart disease and stroke account for a higher percentage of deaths among women than men at all stages of life: 42% of women with heart attacks die within the year, but only 24% of men do •Women account for approximately half of the HIV/AIDS cases worldwide •Women are more likely to be depressed than men •Women are at substantially greater risk for Alzheimer's than men •Substance Abuse and Mental Health Services Administration are targeting six areas for attention: -physical and sexual abuse of women -women as caregivers -women with mental and addictive disorders -women with HIV/AIDS -sexually transmitted disease or tuberculosis -older women -women detained in the criminal justice system

Strategies for Evidence-Based Care

•Ongoing emphasis on the adoption of EBM •Ongoing development of computer-based models •Ongoing clinical trials •Keep guidelines current •Incorporate economic analysis into clinical protocols to enhance cost-effectiveness of care delivery •Restructure reimbursement to reward best achievable outcomes

Racial Ethnic Minorities

•Over 34% of U.S. population is minority -Black Americans - 12.2% -Hispanic Americans - 15.4% -Asian Americans - 4.4% -American Indians and Alaska Natives - 0.8%

Institute of Medicine's National Roundtable on Health Care Quality Star:

•Overuse, Underuse and Misuse

Four Main Types of Access

•Potential access •Realized access •Equitable or inequitable access •Effective and efficient access

Emerging Change - Rise in healthcare consumerism ...

•Powerful Drivers for Consumerism -Expectations - now being compared to other industries -Financial - more cost shifting to consumers -Transparency - means to improve quality and informed choice -Physician influence - is being challenged by primary care options and disruptors -Brand loyalty and equity - who they trust with consumer purchasing - www.joepatient.com - Are health systems going to build enough loyalty to compete with major brands and other industries?

Mental Health Professionals

•Psychiatrists -physicians -postgraduate training in mental health -have power to prescribe prescriptions, and admit patients •Psychologists -usually have doctoral degree, some masters -interpret and change people's behavior -cannot issue prescriptions -use psychotherapy and counseling

What Is Health Policy? Star:

•Public policies -Decisions made in the legislative, executive, or judicial branches of government -Direct actions, behaviors, or decisions of others -When they pertain to or influence the pursuit of health, they become health policy •Health policy -Aggregate of principles, stated or unstated .... That Characterize distribution of resources, services, and political influences impacting the population •Public policies -Supposed to serve the interests of the "public" -Mostly all Americans -Or likely voters -Or those that are politically active -Or those that communicate with representatives -Or donors -Mostly older, more identified with a party •Public policies - legislators and policy makers tend to respond to active Americans views and wishes -Politicians lean toward their own ideology or advance their own agendas -Policy making and politics are closely intertwined -Influenced by the political party in power -Follow up of campaign promises to retain power -Party-line division •Uses of policy -Regulatory tools - prescribe and control behavior of a particular group with monitoring and sanctions •Stds with Medicare state insurance, IRS, JC, Phy stds -Allocative tools - direct provision of income, services, or goods to certain groups of individuals or institutions •Distributive - spread benefits throughout society (NIH) •Redistributive - benefit certain groups by taking and sharing wealth ... Medicaid and CHIP ... ACA as well

Quality Assessment and Assurance Star:

•Quality assurance is based on the principles of total quality management (TQM). -Referred to as CQI •Donabedian model. -See Figure 12-9 •Processes that improve quality -Clinical practice guidelines -Cost-efficiency -Critical pathways -Risk management

Do We Need to Contain Costs?

•Reasons to control costs: 1) Health care consumes a greater percent of the total economic output •Resources are limited •Other economic uses are curtailed 2) Limited resources should be directed to their highest value 3) Corporations bear the additional cost of doing business 4) Public spending for health care will become unsustainable

Community and Migrant Health Centers

•Service to low income populations on a sliding-fee scale •Serve over 18 million patients per year: •Offers primary and prevention care •Hard to attract physicians here

Future of Evidence-Based Health Care

•Strategies for evidence-based care -Leaders must adopt evidence-based guidelines in their organizations. -Systems consultation is a relatively new strategy. -Development of computer-based models incorporating EBM. -Mechanism for auditing and providing feedback. -Future practice guidelines must incorporate economic analysis. -Financial incentives and provider reimbursement. •Strategies for comparative effectiveness and patient-centered research -Seven steps when conducting CER 1.Identify new and emerging clinical interventions. 2.Review and synthesize current medical research. 3.Identify gaps between medical research and clinical practice needs. -Seven steps when conducting CER (continued) 4.Promote and generate new scientific evidence and analytic tools. 5.Train and develop clinical researchers. 6.Translate and disseminate research findings to stakeholders. 7.Reach out to stakeholders via a citizens forum. •High spending does not deliver better outcomes •Better value through evidence-based medicine (EBM) -Quality can be improved while reducing costs by reducing misuse and overuse -Evidence-based clinical practice guidelines—best practices, proven therapies -EBM's full potential still lies in the future

Technological Forces

•Technology will continue to revolutionize health care, but cost increases will create challenges •Technologies that increase self-reliance and cost efficiency will receive much attention •Utilization control measures could also receive attention as technology increases expectation and demand •Reliance on technology now??? How???

The Uninsured

•Tend to be: -less educated, poor -working in part-time jobs and/or employed by small firms -younger 25-40 year olds •Medically uninsured are employed but not covered due to: -employer does not offer health -employee does not qualify, too few hours worked -can't afford •Uncompensated care costs covered by Medicaid, federal grants to nonprofit hospitals and charitable organizations •Ethnic minorities are more likely than whites to lack health insurance. •Most of the uninsured population comprises young workers. •Uninsured persons are in poorer health than the general population. •ACA made progress in reducing the uninsured.

Health Professional Shortage Areas (HPSA)

•The Health Professions Educational Assistance Act of 1976 provided for HPSAs •Three different types of HPSAs: -geographic areas -population groups -medical facilities

Social and Demographic Forces

•The US is becoming bigger, older, and ethnically diverse •Effects on the need for health care and how the needs will be met •The nation's ability to afford health care; growing populations of the elderly, disabled, and Medicaid beneficiaries: -Expanding government programs are on an unsustainable financial path -Implications for supply of health professionals •Cultural factors will create ongoing challenges •Uninsured illegal immigrants tap into resources •Personal lifestyle choices cannot be fully incentivized to assure health .... Risk is not realized enough

Implications of External Forces Star:

•The nature of change in health care depends on complex interactions between these forces and the way opportunities are garnered or foregone •Implications for cost (affordability), access, and power balancing •Free market forces do not drive US health care - the government has been a major player that wields legal and regulatory powers. Yet, the government needs the power sector. Tension and power balancing between the two sectors will continue. •Delivery of health care is closely tied to the nation's economic health •The Pandemic will reveal and change everything ....

What If?

•The seeds for health care reform have already been sown? •Any future reforms will build on the ACA, but some mandates would be relaxed •Regardless, overall cost control will remain a nagging issue •Coronavirus Effect on US Healthcare?

Leadership Theory Star:

•There will always be bad bosses to teach us what NOT to do •There will always be great bosses to teach what to do •Leadership can be learned and developed •Your are responsible to become great leaders BONUS ANSWER

The Chronically Ill and Disabled

•This demographic presents challenges to our health system that is oriented toward acute care •Chronic disease accounts for 75% of the total medical expenditure •Chronic illness is a disease or injury with long-term symptoms, three or more months •Disability is a person's short-term or long term limitation or inability to perform tasks that were previously done unaided

Star: Cost of Health Care

•Three meanings: 1) Price: physician's bill, prescription bill, premiums 2) National perspective: how much a nation spends on health care (health care expenditures) 3) Provider perspective: cost of production (staff salaries, capital, supplies) •Trends in national health expenditures •Should health care costs be contained? -Three sources to assess if spending too much 1.International comparisons 2.Rise in private sector health insurance premiums 3.Government spending on health care for beneficiaries

Affordable Care Act and Quality of Care

•Three objectives 1.Make health care more accessible, safe, and patient centered 2.Address environmental, social, and behavioral influences on health and health care 3.Make care more affordable •Organizations are incentivized to provide high-quality care in two ways. -Penalized for failing to report quality measures -Sharing in the savings generated by quality measures •The number of patient safety and medical errors has decreased since 2010. •Patient-Centered Outcomes Research Institute (PCORI).

Future of Long-Term Care Star:

•Three trends supporting institutional care 1.The number of informal caregivers has been declining relative to elderly population growth. 2.Serious accident victims, dementia, and serious illnesses will need institutional care. 3.Current ACA policy penalizes hospitals with excessive readmissions within 30 days. •Baby boomers will start needing LTC in 2025 •Six main areas of concern need to be addressed: 1.Financing: reform is needed in both public and private financing 2.Resources: H and CBS has not reduced Medicaid spending 3.Infrastructure: (1) models of culture change, (2) care coordination and transitioning, (3) single point of entry into the LTC system Six main areas of concern need to be addressed: 4.Workforce: a deficit of direct care workers is projected 5.Regulation: contradictory and inconsistent application of regulations; no quality monitoring in H and CBS 6.Information technology: interoperable IT systems are needed

Summary

•U.S. demographic landscape continues to change. •Primary care delivery presents a major obstacle. •Financing and delivery of LTC further strains the U.S. system. •Technology will play a major role. •International threats.

Children and the US Health Care System

•US characterizes children's into three sectors: -personal medical and preventive services sector (primary and specialty care) -population-based community health services sector (e.g. immunization, abuse prevention, rehab, case management, referrals) -health related support services sector (e.g. nutrition, rehab, family support)

Star Framework to Study Vulnerable Populations

•Vulnerability -Predisposing - race, gender, geography -Enabling - insurance, homelessness -Need characteristics - mental health, disability, disease •Three vulnerability model characteristics -Comprehensive -General -Convergence

Women and the US Health Care System

•Women are the principal users of the health care system, both for themselves and as the family care coordinator -Until the age groups 65 and older, women have higher physician utilization rates than men -However, hospitalization rates are comparable for men and women •Women work more part-time jobs than men, receiving lower wages, and with more interruptions in their work histories; thus they are at a higher risk to be uninsured, and are more likely to be covered as dependents under their husbands' plans •Women are twice as likely to be covered under Medicaid because the program is linked to Aid to Families with Dependent Children (AFDC)

Designer Babies Star:

•https://www.youtube.com/watch?v=TNdGAFc_45A

Gattaca - Genetic Mapping and Discrimination

•https://www.youtube.com/watch?v=lP1cCjBkWZU