PHTH2350- chapters 26 through the end

ultimate challenge to public health in the 21st century

educating the public and policy makers abut the role of nonmusical factors in determining people's health and convincing people of the importance of the core public health functions in protecting and promoting the health of the entire population

most important ethical dilemma in the medical system according to public health advocates

inequities in access to care

small-area analysis

method of examining how medical practice varies across geographic areas - has been applied over the past several decades to a broad range of practices and procedures - repeatedly, wide variations have been found, with no apparent reason for the differences in practice - beginning in 1996, D. John Wennberg began publishing the Dartmouth Atlas of Health Care series, which examines Medicare/aid data : all over the country, variations occur in treatments for prostate cancer, breast cancer, heart disease, and many other common conditions - small-area analysis called attention to the lack of scientific evidence of which doctors and patients base decisions about how various medical conditions should be treated

outcomes research

the epidemiological study of medical care - whereas epidemiology usually examines the disease-causing effects of exposure to agents, outcomes research examines the health effects of exposure to medical interventions - controlled clinical trials are one form of outcomes research, but practical/financial/ethical barriers pose challenges - collects/analyzes data generated by the everyday practice of medicine in an effort to reach conclusions on benefits/risks of various interventions for various types of patients

relative importance of medical care for public health

to what extent does medical care contribute to improving the health of the population as a whole? - analysts weigh the contribution of medical care with other factors that contribute to health (genetics, behavioral patterns, social circumstances, environmental pollution) - researchers have identified that a shortfall in medical care is far from the most important cause of premature death (only 10%) - in fact, resources devoted to medical care are far out of proportion to their contribution to health: the enormous investment in medical care uses up resources that would otherwise be available to address other factors that affect health (education/housing/environment) - studies have shown that health is not correlated with resources devoted to medical care (Wennberg comparison of healthcare costs and health status in Boston and New Haven)

Medicare

- created in 1965 as a mandatory insurance program for people over 65 - part of the Social Security system - workers pay into the system through deductions from their paychecks; employers pay a tax on their payroll ; workers are entitled to benefits when they reach retirement age - two main parts: part A (covers hospital insurance, most people enrolled) and part B (pays doctor bills and other outpatient costs, voluntary and requires a monthly premium) - similar to traditional health insurance: doctors/providers paid on a fee-for-service basis, patients required to pay deductibles and copayments - part C was added in 1997 and gives people more flexibility in health plan choices - part D added in 2003: creation of a new prescription drug plan

Medicaid

- created in 1965 as a welfare program for the poor - costs shared by the federal government and the states - eligibility determined by income and varies from state to state - medical bills paid directly by the state/local government to the provider, usually at a low and fixed rate for each service

issues with Medicare

- escalating costs: each year, the program pays out more than it collects in premiums, and Congress has repeatedly tried to make adjustment to save it from bankruptcy - federal budget spending on Medicare is growing, although more slowly since the ACA - attempts to cut costs are politically delicate because older adults are fiercely protective of their entitlements - most beneficiaries have some kind of supplemental insurance plan

2009 Consumers Union report

- evaluation of progress in implementing the IOM's report recommendations - gave the country a failing grade - reported that few hospitals had adopted measures to prevent medication errors and that the FDA rarely intervened ; computerized prescribing systems have not been widely adopted ; no national system of reporting medical errors

2015 National Patient Safety Foundation follow-up to the IOM report

- found that some progress had occurred : increased recognition of the problem - major problems remain: about 10% of hospital patients incur an adverse event (fall, hospital-acquired infection, preventable negative drug effect...), half of surgeries involve a medication error or dangerous drug effect, more than 5% of outpatient diagnoses are in error each year

health status of the older population

- greatest public health concern for those older than 65 is long-term chronic illness, disability and dependency - majority of the older population is in good health - causes of death are essentially the same as those of the general population: CVD and cancer lead the list - unanswered question of whether longer life expectancy means more healthy years or just longer periods of chronic illness and disability --> financial solvency of the Medicare system will be highly dependent on the answer - experts agree that the 20th century saw a "compression of mortality" (=death increasingly became concentrated in a relatively short age range at about the biological limit of lifespan), but we don't know if this will be accompanied by a compression of morbidity - evidence is beginning to show a compression of morbidity

ethical issues in medical resource allocation - organ transplants

- has become increasingly successful due to improved anti rejection drugs, but the problem of how to distribute scarce resources has resurfaced (we never have enough donors, especially for livers, where there is no substitute treatment) - policy on distributing organs has been controversial - task of matching organs with patients is handled by the United Network of Organ Sharing (UNOS): maintains a computerized network of organ recovery centers, patients are prioritized according to how urgently they need the organ - 2009: Steve Jobs unexpectedly receives a liver transplant some time after being diagnosed with pancreatic cancer --> questions raised about jumping the waiting list

health of schoolchildren

- has been a public health concern since the late 19th - to control the spread of communicable disease, cities began to employ medical inspectors to examine kids who showed signs of illness - school doctors/nurses began testing kids for eye problems and other physical impairments - not allowed to provide medical treatments because of the opposition of the medical establishment - laws began requiring that children be immunized before starting school - it is a source of frustration to public health practitioners that school health programs are not integrated with medical services: many children left with health problems that are repeatedly diagnosed by go untreated

AHRQ National Healthcare Quality and Disparities Report

- has been provided to Congress annually since 2001 - tracks disparities in healthcare access and quality across racial, ethnic, and economic groups - access to care: percentage of white adults without health insurance continues to be much lower than that for blacks and hispanics, although the gap is shrinking - quality of care: gap between whites and minorities has generally persisted

issues with Medicaid

- has never worked as well as expected, but since the ACA it covers many more poor Americans - ACA originally expanded Medicaid to cover all low-income adults, but a supreme court decision allowed states to opt out of the expansion --> in states that implemented it, even childless adults are eligible ; in states that did not, childless adults are not covered - in some states, the fixed fees that Medicaid pays to providers are so low that doctors are unwilling to participate in the program --> makes it hard for families to find someone to treat them other than poor-quality "Medicaid mills" - growing costs of Medicaid are placing a strain on many state budgets --> using funds that otherwise would be devoted to education or other services - 85% of beneficiaries are children, their parents, and pregnant women, yet 25% of the spending goes to LTC for the elderly/disabled

ethical issues in medical resource allocation - kidney disease

- hemodialysis (blood-cleansing) first developed in the 1970s for kidney failure --> shortage of dialysis machines --> "God Committees" formed to select the most worthy candidates --> favored those who had jobs, family responsibilities, youth, good general health, and strong motivation - 1972 End-Stage Renal Disease Act funded dialysis treatment for all Americans who needed it without selection criteria --> created a new group of citizens with a right to medical care based on their diagnoses - advocates for patients with other conditions (hemophilia, heart/lung disease) tried to persuade Congress to fund their diseases too --> declined to extend the benefit to ppl other than kidney patients

growth in medical care expenditures in the US

- historically, the rate of increase has exceeded to overall rate of the economy, so that medical costs have constituted an increasingly larger percentage of the nation's GDP - expenditures on health have risen all over the word, but the US spends far more on medical care per person than any other country - no evidence that Americans are healthier as a result of the greater expenditures

general approaches to maximizing health in old age

- improving health-related behavior: smoking, physical inactivity and obesity greatly impact health - COPD is caused almost entirely by smoking; osteoporosis and disorders of the mouth are made worse by smoking; smoking is a major risk factor for CVD and cancer - diet/exercise affect the risk of both CVD and cancer; overwieght/obesity increase risk of CVD, cancer, diabetes, and arthritis - percentage of ppl who are obese/overweight actually decreases after 75: obese people die at an earlier age

Oregon plan

- late 1980s: Oregon realized its Medicaid budget was not big enough to provide comprehensive coverage for all its poor citizens - state undertook a plan to spread its resources over a bigger number of people by limiting the services for which it would pay - 1st move was very controversial: decided not to pay for organ transplants (justification was that the funds needed for 34 transplants could provide prenatal care and delivery for 1500 pregnant women) --> national uproar ensued - the legislature, led by John Kitzhaber, decided to develop a more acceptable policy : new approach focused on life-saving treatments for serious conditions and tried to eliminate less effective therapies for less serious conditions, by making a prioritized list and to draw a line below which treatments would not be covered - commission formed to develop the list - top of the list: acute problems that could be fatal or for which treatment would provide full recovery (maternity care, preventative care for kids...) - bottom: ineffective treatments or those that did not extend/improve life (some cancer treatments, AIDS treatment)

preventing disease/disability in old age- vision/hearing impairment

- leading causes of visual impairment among the elderly: cataracts, glaucoma, macular degeneration, diabetic retinopathy - cataracts: wearing sunglasses, no smoking, surgery to correct the lens - glaucoma: secondary prevention (eye checkups) - macular degeneration: no known way to prevent the disease - hearing loss most often caused by exposure to excessive noise - products can help people to hear better (hearing aids, telephone amplifying devices, etc) - medicare does not cover glasses and hearing aids --> barrier

consequences of lack of insurance

- leads to poorer outcomes when people are sick - uninsured people tend to postpone seeking medical care when they are sick, and they may be denied care - if they are sufficiently sick they may go to the ER (required by law to treat them), and the costs may be borne by shifting it to other players --> increases charges for insured patients - the uninsured are more likely to be hospitalized for preventable illness than the insured patients, and are less likely to survive a serious illness

providing charity for the poor

- long history in the US - treatment was often provided by part-time volunteer physicians --> combined their services with research and the teaching of medical students - establishment of free dispensaries starting in the late 18th century, often connected to medical schools --> services were quite controversial ("dispensary abuse") - early 20th: city health departments began setting up clinics for the control of infectious diseases and the prevention of infant mortality

preventing disease/disability in old age- medications

- many treatments for chronic conditions have unwanted side effects that can impair health and quality of life - kidney/liver function is often impaired in older people --> increased sensitivity to drugs - reducing the risks from adverse drug reactions requires education and vigilance by everyone involved - elderly patients' needs for medications should be reassessed regularly: in some cases, the potential benefit of a drug may not be worth the damage it could cause to other aging organs - urgent need for more research on the risks vs benefits of various types of drugs in the elderly - better coordination and monitoring of medical care is also necessary

inequities in medical care

- medical care is rationed by ability to pay, but also there are racial inequities in how care is delivered even when individuals are able to pay for it - blacks/hispanics are less likely than whites to receive the most effective treatments for heart disease, HIV infection, asthma, breast cancer, etc, even when their income and insurance status are equal to whites - blacks have the highest death rate and the shortest survival of any racial/ethnic group in the US for most cancers - blacks are less likely to survive 5 years after diagnosis, most likely due to their tendency to be diagnosed at a later stage, when the disease has spread - blacks are less likely to receive timely and high-quality treatment

licensing and regulation of medical care

- medical profession has been willing to submit to some forms of government regulation - licensing of qualified medical practitioners (physicians, nurses, etc) protects the prerogatives of the professionals from encroachment by unlicensed people and ensures quality of care for patients - licensing required to practice in each state ; states can also establish requirements to maintain/update their skills to retain their licenses ; states also have the power to discipline professions for incompetence/misconduct - states also license/regulate medical facilities (hospitals and nursing homes) - institutions may also seek accreditation from a private organization (the Joint Commission) - schools also seek accreditation as a measure of their quality - governments have attempted to use regulatory approaches to restrain the growth of medical costs by requiring certificates of need before new facilities can be built or new equipment purchased --> efforts have proved ineffective

When is medical care a public health responsibility?

- medical treatment of communicable diseases: one sick individual can infect many others, so public health has taken a major interest in all aspects of infectious disease control - city and country health departments have traditionally operated clinics for diagnosis/treatment of infectious diseases - early 1990s: threat of reemerging TB was so serious that the NYC Dpt of Health provided a program of DOT where public health nurses were sent to track down patients - provision of emergency services: emergencies re unpredictable and can strike individuals at any time/place - Highway Safety Act of 1966 marked beginning of federal government pressuring states/localities to develop procedures for quick access to emergency care - since then, communities have developed 911 phone-response networks, trained EMTs, dispatched ambulances using a centralized system, provided evacuation helicopters in rural areas, etc - still, quality varies greatly - many laws require that emergency rooms treat any patient with a life-threatening condition regardless of their ability to pay, but many hospitals will then transfer poor/uninsured patients to public/charity hospitals --> laws against "abandonment" avoid this - most US citizens do not have a general right to medical care - exceptions: veterans and prisoners - VA hospitals: designed to treat war-related injuries but also serve as a safety-net for low-income veterans without other sources for care - prisoners are entitled to medical care because they are unable to seek care on their own

health insurance

- most Americans get insurance as part of n employee benefit package, which covers the worker and family - this approach to paying medical bills became dominant after WW2 --> satisfied most groups over the next 3-4 decades - traditional health insurance (the kind provided by most employers until recently) works like car insurance: regular premiums are paid to the insurance company, so when covered individuals get sick, their bills are reimbursed by the company ; sometimes their are deductibles and copayments (=flat fee or fixed percentage of the remainder of the bill) --> fee-for-service approach permits doctors to make decisions with no consideration for cost, which has escalated costs

preventing disease/disability in old age- falls

- most osteoporotic fractures occur when elderly people fall - many older people have a high risk of falls because of medical conditions that affect their mobility (arthritis, stroke, Parkinson's etc) - other risk factors: vision impairment, muscular weakness, problems with balance, medication side effects, use of 4+ prescription drugs (especially psychoactive drugs) - Mayo Clinic recommends 6 measures that older people can take to prevent falls: consult with physician to form a plan; have meds reviewed, exercise regularly, improve lighting in homes and reduce fall hazards; wear comfortable and sturdy shoes; make use of assistive devices (hand rails on stairs, grab bars in the shower/bathtub)

health services research

- new field of research that included results from small-area analysis - attempts to understand the reasons for the observed variations in medical practice and to determine what treatments lead to the most desirable outcomes - studies the effectiveness, efficiency, and equity of the healthcare system - way of trying to asses the quality of medical care, but may also lead to insights on how to control costs and improve access

medical costs of the elderly

- number of people enrolled for Medicare coverage has more than tripled since 1966; the number of workers whose earnings contribute to the system is growing at a much slower pace - same problem applies to Social Security - Medicare has major benefit gaps and cost-sharing requirements - Medicaid acts as a Medigap policy for poor elderly persons: increasingly called on to pay for services for the elderly that Medicare does not cover - past efforts to slow government expenditures for elderly bills have meant that these patients bear a high percentage of the costs through higher premiums and copayments - another approach has been to reduce reimbursement to medical providers --> could induce some providers to refuse treatments to Medicare patients - introduction of Part D in 2006 helped many pay for their meds, but has many drawbacks: private plans vary widely, and the benefit structure has a coverage gap ("doughnut hole")

public health and the aging population

- older people tend to have poorer health than do younger ones: more chronic illnesses, more likely to suffer limitations of their ability to participate fully in the activities of their community --> poorer quality of life, and higher medical costs - quality of life in later years depends significantly on lifestyle in youth and middle age: to the extent that public health succeeds in promoting healthy behavior throughout the lifespan, there is a payoff in improved health and quality of life for older people - financial barriers of Medicare are increasing, and the medical care for the elderly is being rationed

the US before the ACA

- only industrialized nation (except South Africa) without a national plan for providing medical are - 2008: more than 20% of the population ages 18-64 did not have health insurance - for many, there was no guaranteed access to health care except for emergency care

results of the oregon plan

- opposition on legal, social, and ethical grounds -1991: Dpt of Health and Human Services denied Oregon to implement the plan because it violated the Americans with Disabilities Act - after some revisions, it was approved by the Clinton admin in 1993 - over 100k people were added to the Medicaid program as a result - critics say the policy would be more equitable if everyone (not just the poor), were included in the rationing proposal: the US medical system as a whole is rich enough to give care to everyone - health policy experts have praised the plan's focused on medical necessity ; and, the plan called attention to the need for more research on outcomes of various treatments - however, the plan eventually collapsed - the experiment made many people uncomfortable because they were confronted with the idea that rationing medical care might be necessary/desirable --> it has been going all along however

preventing disease/disability in old age- osteoporosis

- osteoporosis: condition characterized by "porous bones", which tend to break easily - common with age, especially in women, and especially in the years following menopause - smoking/alcohol increase the risk, while obesity reduces the risk - white women have the greatest risk - surveys have found that the average amount of calcium women obtain in their diet is significantly less than the recommended amount - no symptoms: most older people are unaware that they have the problem until they suffer a broken bone - hip fractures are the most serious consequence: might lead to substantial disability and death - Surgeon General's report makes multiple recommendations for prevention: getting adequate amounts of calcium (1000mg per day if under 50, 1200mg if over 50), being physically active at least 30mins per day for adults and 60 for kids, bone scan tests for all women over 65

rationing

- our society has never been willing to discuss trade-offs between costs and quality of medical care - because third parterres pay for care, people have come to believe that costs should not be considered in decisions about medical treatments --> at the same time, people naturally seek out insurance plans with the lowest premiums --> society demands that the healthcare system maximize quality while minimizing costs, but it has placed a taboo on the consideration of cost - rationing is a dirty word when it applies to medical care, but it is inevitable - in economics, rationing is simply the process of allocating goofs in the face of scarcity

biotechnology

- promises to solve many medical problems with new drugs and procedures, but those drugs/procedures will also contribute to skyrocketing costs - public health should have a voice in deciding how many of these innovations our society can afford

What does the medical system do?

- provides preventative care: immunizations against infectious disease, monitoring of pregnancies and provision of "well-baby care", testing of adults for risk factors (high cholesterol/BP) of CVD - secondary prevention measures: screening for early detection of diabetes and cancer, early interventions to correct problems - saves lives, prevents suffering and disability - called upon to eat with the consequences of failures in public health

establishing a national health insurance plan

- repeated attempts in the 20th century - during this time, most industrialized countries were setting up such programs (Germany established the 1st national system of compulsory sickness insurance in 1883) - efforts were made in the US before WW1 but were derailed by the war - another attempt made in the 1930s as part of the New Deal, but health insurance was not included in the Social Security Act - after WW2, President Truman proposed a single health insurance system, but it failed - each time, the medical profession opposed government involvement in medical care as "socialized medicine" 1965: victory achieved under President Lyndon Johnson with the laws for Medicare and Medicaid --> designed to remedy the main problems with employer-based insurance (stops when retired, and leaves the poor/unemployed out of the system) - early 1970s: president Nixon tried to expand the programs, but his efforts were derailed by the Watergate scandal - no further efforts until President Clinton was elected in 1992, promising health insurance for all --> defeated - he did however negotiate the CHIP program: joint federal-state program expanding coverage to children in families that earn too much to qualify for Medicaid - 2010: Obama passes the ACA

Resistance from the medical profession to be included in the domain of public services

- since the end of the 19th century (discovery of bacterial causes o diseases), public health has claimed the prevention/treatment of infectious disease as its responsibility, while doctors have resisted that claim - early 20th: doctors fought reporting requirements for TB/veneral disease cases, opposed the creation of public health clinics nd centers --> they perceived it as an attack on their economic interests - medical establishment was able to prevent the US from providing for its citizens the public assurance of needed medical care

Keystone ICU project

- system set up as part of a safety initiative in Michigan; funded by the AHRQ and instituted in 2004 in 103 ICUs - goals: prevent catheter-associated bloodstream infections and deaths associated - short checklist of best practices related to catheter use - incidence dropped to less than 20% of what it was before procedures implemented

preventing disease/disability in old age- oral health

- tooth loss, dental caries, periodontal disease, salivary dysfunction, cancer and precancerous conditions, chronic pain - oral health in old age depends on healthy behaviors throughout life - older people can improve it by instituting healthier habits: quit smoking, use better oral hygiene, use professional dental services - medicare does not cover these services

reasons for variations in medical practice: use of specific treatments

- variability in the use of specific treatments reflects the degree of uncertainty facing physicians regarding their relative efficacy - variations in practice are far greater in some medical conditions than for others - in many cases, doctors are unaware that their way of treating a condition is unusual, and they will change their patterns of practice when presented with evidence - however, inappropriate use explains only a small part of the wide variability observed for many procedures - for many medical conditions, more than one response may be appropriate: when faced with a patient suffering from a specific illness, one physician may prefer conservative treatment using drugs and "watchful watching", while another may believe that immediate surgery is indicated

strategic planning for public health

- 1979: US Public Health Service adopts "management by objectives", a technique that requires managers to jointly define a set of measurable goals, use these goals as a guide to their actions, and regularly measure progress --> especially useful in decentralized organizations - to develop goals for the year 1990, the Public Health Service enlisted a broad range of participants from within and outside government to specify a set of objectives: goals published as "Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention" --> set targets for reducing mortality rates in different age groups - any state/community/group that applied for federal funds for a public health program had to justify its request by showing how the project would contribute to achieving one or more of the goals - the goals were met for 3 of the 4 age groups (adolescents/young adults not met) - 1987: process began to set objectives for the next decade --> "Healthy People 2000" - 2001: final review published to evaluate the progress made --> progress achieved on more than 60% of the objectives - 2000: "Healthy People 2010" launched with 2 overall goals (increase quality and years of healthy life; eliminate health disparities) - 2011: final review published - 2010: "Healthy People 2020" launched with 4 overarching goals - planning now underway for "Healthy People 2030"

HRT

- 1990s: increasing evidence appeared suggested that HRT might have advantages for older women --> studies showed it was associated with lower rates of heart disease and osteoporosis - however, HRT increases the risk of breast and uterine cancer - 1997: publication concluded that HRT reduced women's overall risk of dying as long as they took the hormones - publication that was part of the Women's Health Initiative crushed this: found that HRT increased the risk of heart disease, stroke, and Alzheimer's (apparent benefits of estrogen were caused by the confounding factor that women who chose HRT were healthier)

approaches to controlling medial costs

- 1st cost control effort was by the federal government: imposition of price controls by president Nixon --> temporarily moderated cost increases, but providers adapted to the lower fees paid for each service by increasing the quantity of services, so spending continued to rise - another approach focused on limiting spending on new facilities and technology (major strategy used by other OCED countries): in the 70s, the federal government tried to constrain the supply of hospital beds and high-tech equipment by creating regional planning agencies to issue certificates-of-need--> they didn't have limits on budgets, so there were few incentives to control the expenditures --> programs gradually abandoned - in the 80s, the Medicare program devised a payment system designed to provide incentives for hospitals to limit the length of each hospital stay : Medicare payed a flat fee for each hospital stay (an amount based on the illness category or diagnosis-related group, and the average cost of treating similar patients throughout the country) --> if a hospital could cure the patient in a shorter time than average, they could keep the extra cash, but if the took longer, they had additional costs - one result was to move treatment out of the hospital - hospital stays are on average much shorter now

ACA

- 2010 - key component was the individual mandate, a requirement that all Americans have health insurance or pay a fine ; also required any business with 50+ workers to provide coverage or pay $2000 per employee - required states to have affordable insurance exchanges (individuals can shop for a plan that meets their needs) - requirement to expand Medicaid to cover low-income adults - some other provisions of the ACA have proved popular, including an expansion of coverage for young adults on their parents' plan up to age 26 ; Medicare now provides older adults with preventative benefits - contraception now required by law --> controversial - may of the insurance company abuses (cancellation of policies when a patients' costs rise) outlawed by the new law - also established a Center for Medicare and Medicaid Innovation to begin testing new ways of delivering care - ACA was scheduled to be fully implemented by 2015, but the constitutionality of it was challenged in court - individual mandate was the most contested issue --> upheld in 2012 - court's decision also restricted the expansion of Medicaid, allowing states to opt-out - trump administration has done as much as possible to further damage the ACA: eliminated subsidies for low-income people and families who bought policies on the exchanges, and passed a major tax reform law that abolished the individual mandate (2017)

trends in the aging population

- 3 component groups of the elderly: the "young old" (65-74), the "aged" (75-84), and the "oldest old" (85 and older) - in 2017, the "oldest old" was the fastest-growing age group other than the baby boomers - females increasingly outnumber males in older age groups : women have a longer life expectancy - racial/ethnic diversity among the elderly is expected to increase - Social Security and Medicare have helped most of the older population stay out of poverty: percentage living in poverty has declined

how is the money spent on medical car paid for?

- 36% by private health insurance - 22% by Medicare - 18% by Medicaid

1999 IOM report "Too Err is Human"

- 44k-98k deaths per year in the US caused by medical errors (more than motor vehicle accidents, breast cancer, AIDS...) - placed medical error among top 10 causes of death - before it was published, medical errors were blamed on failures by individual doctors/nurses --> the report shifted the blame to the medical care system, characterizing it as decentralized and fragmented - the report made recommendations, beginning with the creation of a Center for Patient Safety within the AHRQ to set national goals, track progress, develop a research agenda eyc - another recommendation was that (as in the airline industry) accidents and near-misses should be reported so that error could be investigated --> mandatory nonpunitive system - recommended that the FDA require that drug naming/packaging/labeling be designed to minimize confusion

problems with access to medical care

- 8.5% of population lacked health insurance in 2018 for the whole year, even more for part of the year (15.5% in 2010, the year the ACA was passed) - most of the uninsured are poor, and the percentage of uninsured citizens decreases as their income increases - percentage of uninsured kids has decreased since CHIP was established - young adults are the group most likely to be uninsured ; minority groups are more likely to be uninsured than white Americans ; before the ACA many of the uninsured were patients with chronic diseases who were closed out of the market because of policies that denied coverage for preexisting conditions (prohibited now) - access problem is closely related to the cost problem: monthly premiums rising in proportion to wages, making it increasingly expensive for employers to provide insurance

preventing disease/disability in old age- Alzheimer's and Other Dementias

- Alzheimer's disease is the most common cause of dementia in the elderly- other causes include vascular dementia, traumatic brain injury, infections, toxic exposures, etc - no cure for Alzheimer's - several genes have been identified that influence the risk that an individual will develop Alzheimer's - non genetic risk factors include the risk factors for CVD: weight control, physical activity, avoidance of smoking, treating high BP and cholesterol, preventing diabetes, etc - studies have shown that formal education seems to protect the brain, proving a "cognitive reserve"

proposals for rationing

- Richard Lamm, former governor of Colorado: suggested in 1984 that older people have a duty to die an get out of the way (as they consume increasing amounts of medical care, society is cutting back on care for children and working people, jeopardizing their future) - most proposals for rationing involve denying expensive live-prolonging technology to people older than a set age --> seems unfair because it punishes people who have taken care of their health - most proposals say to deny it to people who are not expected to achieve a substantial improvement in quality of life from the treatment - in some cases, expensive treatments are denied to people who are seen as causing their own medical problems through unhealthy behavior - current interest in assisted suicide is one consequence of patients' fear that they will not receive humane care as they lose control and independence --> euthanasia is one step further and would greatly cut costs - desperate families might resort to "granny dumping" - according to John Wennberg and his Dartmouth research group, a significant amount of the spending on end-of-life care is wasted, and that more aggressive care is not necessarily better quality care - higher-intensity pattern of care may actually have worse outcomes - Dartmouth researchers note that Medicare costs could be greatly reduced, and end-of-life care might be more humane, if all parts of the country used the same patterns of care as the low-cost-areas - greatest hope of reducing costs is the possibility of improved health (compression of morbidity): Fries-Koop consortium proposal says that the goal of an integrated healthcare system is to postpone the onset of chronic infirmity by reducing risk factors, and that demand for medical care could be reduced by educating individuals to assume more responsibility for their own health

Issues around medical care

- access to medical care: difficult for many who lacked insurance - quality of medical care --> success after the ACA

why do costs keep rising? (in the US)

- administrative costs: administrative complexity is the largest source of healthcare spending waste - (6 domains of waste: failure of care delivery, failure of care coordination, over treatment or low-value care, pricing failure, Medicare fraud, administrative complexity) - each insurer has its own forms and documentation requirements --> billing/paying for care is much more time consuming and expensive than in countries where the government pays for everything - in trying to control costs, some insurance companies add extra procedures --> paradoxical effects of increasing paperwork - our tendency to see for malpractice when something goes wrong: doctors complain about the price of malpractice insurance --> these costs do not in themselves have a big overall impact, but the fear of malpractice suits may affect a physician's decisions - some doctors may practice "defensive medicine": ordering more diagnostic tests and medical procedures than necessary to document in court that they did "everything possible" for the patient - the US has higher rates of chronic diseases associated with obesity (diabetes, heart disease) - financial incentives for medical providers: in the "fee-for-service" system, doctors/hospitals are motivated to provide more services to increase their income ; performing surgical procedures and using high-tech equipment are more profitable than the more time-consuming practices to talking/listening/etc - growth of specialization among physicians: fewer than 50% of doctors in the US work in primary care --> low pay for PCPs, so many patients looking for an internist or pediatrician may not find one - patient expectations: those with traditional insurance don't have to consider the costs of their care, so they demand "the best" ; in the medical marketplace, the seller rather than the buyer determines what the buyer needs, and sellers also set the price --> because the bill is paid by a third party (insurance company), there is no incentive for the buyer to pick a cheaper option

why do costs keep rising? (in all countries)

- aging population: older people have greater needs for medical care, so they drive up medical expenditures - continual development of new medical technology and high-tech procedures --> very effective, so they are used widely (perhaps too widely)

community health centers

- another source of basic medical care for the poor - supported by federal grants and by payments by public/private health insurance - about 1400 in the US, located in inner cities and isolated rural areas (shortages of medical/social services) - provide primary and preventative care to people who might otherwise not be able to afford it - services paid for by government programs or patients can pay a fee based on a sliding scale according to income - serve as an important safety-net of low-income uninsured people - now serve approx. 20% of uninsured people (8% of US population)

reasons for variations in medical practice: field of dreams effect

- availability of services in a community can influence practice styles - for example, the presence of a greater number of surgeons leads to more surgeries being performed - research has constantly demonstrated an influence of supply on usage when hospital beds are concerned - the number of hospital beds in a community significantly influences the kind of care received by dying elderly people: Medicare patients in areas with more beds are much more likely to spend their final days in a hospital (often the ICU) rather than at home - little evidence to show that patients are helped/harmed by the more intensive care from a hospital, but the differences in use do have a major impact on medical care costs - financial considerations may influence some physicians' medical decision making: evidence shows that when physicians stand to profit from the performance of diagnostic tests, they are much more likely to order such tests

managed care

- became more prevalent in the 1990s because of rising costs - moves the incentives of medicine closer to the mission of public health (=keeping people healthy) - managed care organizations (MCOs) are responsible for all their members, and they receive financial rewards when the need for expensive medical services is averted - incentives for MCOs to keep their patients healthy encourage medical plans to use public health strategies - financial incentives also made medicine economically dependent on public health's effectiveness in preventing unnecessary disease in the community - medicine is driven by the same kind of measurable goals/objectives that public health has been developing: MCOs are required to collect data on the effectiveness of their services and the health status of their members --> common goals provide medicine and public health with strong incentives to work together - popularity has declined since the late 1990s: backlash against many of the cost-control measures, and the benefits of MCOs were not obvious to the public - the ACA compensates somewhat for the failures of the managed care movement by including a number of prevention and wellness measures: insurers required to cover preventative benefits, provision for a Prevention and Public Health Fund which sets aside a specific amount every year to improve health

RAND Health Insurance Experiment

- compared use of services, expenditures, and health outcomes among several groups of consumers who were assigned randomly to receive free care or to pay copayments of varying amounts - evidence showed that higher copayments discouraged patients from seeking care: the more consumers had to pay, the less medical care they consumed, and the free-care group used services costing 50% more than those who had to pay the most - for most of the participants, the extra services didn't impact their health status - however, for those who were both poor and chronically ill, free care did provide significant benefits in health status

twofold challenge for public health with the aging population

1. improve the health of older people by prevention of disease and disability 2. confront the issue of how costs can be controlled in an equitable and humane way

CDC's top 10 list of great public health achievements of the 20th century

1. routine use of vaccination has resulted in dramatic reductions in infectious diseases 2. improvements in motor vehicle safety have reduced motor vehicle- related deaths (engineering efforts and persuading people to adopt healthier behaviors) 3. safer workplaces have reduced fatal occupational injuries and illness 4. control of infectious diseases achieved by improved sanitation, cleaner water, safer food, discovery of antibiotics, and methods of epidemiological surveillance 5. decline in deaths from heart disease and stroke resulting from the identification of risk factors and success in changing behaviors to reduce cholesterol and stop smoking 6. safer/healthier foods have almost eliminated major nutritional deficiency diseases in the US 7. healthier mothers/babies from better hygiene and nutrition, antibiotics, greater access to health care, and technological advances 8. access to family planning and contraceptive services has led to healthier mothers/babies 9. fluoridation of drinking water has reduced tooth decay in children and tooth loss in adults 10. recognition of tobacco use as a health hazard and subsequent public health antismoking campaigns have helped prevent smoking and smoking-related deaths