HE210 Final Exam

EFFICIENCY OF HEALTH CARE

Efficiency is the third criterion for judging a health care system. "Efficiency requires that we produce the combination of goods and services with the highest attainable total value, given our limited resources and technology" (Aday et al., 1993, p. 73). Efficiency is either allocative or production. Allocative efficiency concerns attaining the most valued mix of health care services. Production efficiency refers to producing a given level of health care services at minimum cost. As an example, an allocative efficiency issue is how much to invest in preventive versus curative medical services, whereas a production efficiency issue might concern whether and when to substitute relatively low-cost nurses for higher cost physicians in the provision of health care services. At the microlevel of physician practices, hospitals, and other health care settings, efficiency is assessed using (a) production functions and (b) cost-effectiveness, cost-benefit, and related cost-utility analysis (Aday et al., 1993). These analyses are used to determine, for example, which of two equally effective treatments should be recommended to clinicians. If both are effective, the goal of efficiency suggests that the less expensive treatment is preferable. These kinds of decisions are increasingly made by health care payers. For example, the Commonwealth Fund newsletter (March 2006, p. 1) reports: Washington State's Health Care Authority, which coordinates the Prescription Drug Program for the state's Medicaid, public employee, and worker c ompensation programs, is using an integrated approach to value-based pharmaceutical purchasing. The evidence-based drug review process involves a thorough a nalysis of quality and effectiveness before applying cost considerations. The p rocess, which includes an evidence-based preferred drug list and supplemental rebates from pharmaceutical manufacturers, is producing savings of about $20 million each year to the state— over 5 percent of its Medicaid fee-for-service drug spending—and about $40 million in combined state- federal spending. At the macrolevel, efficiency analysis is based on comparisons between regions, states, and nations. Often, we use international comparisons of health care systems (Aday et al., 1993). We can use WHO statistics and the Commonwealth Fund to contrast the United States with peer nations, including Australia, Canada, France, Germany, Japan, New Zealand, Norway, the Netherlands, Switzerland, Sweden, and the United Kingdom on numerous indicators of cost and available health care resources. In 2014, the United States was ranked first in proportion of its gross domestic product spent on health services (17.7%) and ranked first in per capita total expenditures on health care. At the average exchange rate in U.S. dollars, per capita expenditure was $8,508 in the United States, compared to $3,405 in the United Kingdom, the country ranked first in overall health system performance (Davis, Schoen, & Stremikis, 2010; Davis, Schoen, Stremikis, & Squires, 2014). The United States was ranked second to last in physicians per 1,000 population, and last in number of physician visits per capita. The United States ranked in the bottom of the percentage of those who believe, if they became seriously ill, they would be confident they could afford the care they needed. Overall, the United States ranks last on mortality amenable to health care, last on infant mortality, and second to last on health life expectancy at age 60. Primary care physician survey data also suggests the United States is lagging in adoption of national policies that promote primary care, quality improvement, and information technology. The United States is spending more per capita on health care and providing fewer basic health care resources relative to other countries. Further, the U.S. rankings on various measures of mortality discussed previously in this chapter (see "Population Health Outcomes") suggest that the U.S. health care system is not efficient, because our rankings on life expectancy, quality-of-life adjusted life expectancy, infant mortality, and other mortality rates are consistently lower than those of peer nations spending less on health care.

Industrial Health Service Units

"A range of industrial health hazards exist, from traumatic injury to occupational exposure to harmful substances (e.g., silica, asbestos, and lead). The number of "in-plant" health units in the United States is not known, but there are thousands of them. In small plants (fewer than 100 workers), health services are ordinarily quite rudimentary. They are often limited to a first-aid kit and arrangements with some local health facility to which injured workers may be sent. Very large plants (with more than 2,500 workers) usually have some systematic in-plant health service. Customarily, it is staffed with trained industrial nurses and part-time or full-time physicians. In a few companies, in-plant health services are comprehensive, providing employees with complete medical care for all disorders, job connected or not. The long-term trend in American industry is toward greater concentration of production in fewer large corporations. Although at one time it seemed that concentration might enhance the prospects for improving occupational health programs, in the 1980s there were reductions in service in many large corporations in the name of cost savings (D. Parkinson, personal communication, October 25, 1990). This situation may be changing because of increasing recognition that health is an important factor in worker productivity and the workplace is a viable and practical place to begin." Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail.action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 12:28:44.

What is Health??

"Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." It was adopted in 1946 and has not been amended since 1948 (WHO, 1948, p. 100). Many subsequent definitions have taken an equally broad view of health, including: A state characterized by anatomical, physiological and psychological integrity; ability to perform personally valued family, work, and community roles; ability to deal with physical, biological, psychological and social stress; a feeling of well-being; and freedom from the risk of disease and untimely death.

Other "Fixes" for Problems of Access

"Major tinkering" occurred in the 1960s when the federal government created the Medicare and Medicaid programs. However, in most eras of dissatisfaction with health care, "minor tinkering" with the system prevailed. Three examples of this type of incremental change are the Hill- Burton Act, Emergency Medical Treatment and Labor Act (EMTALA), and Health Insurance Portability and Accountability Act (HIPAA) The 1946 Hill- Burton Act funded hospital construction in underserved areas. It was actually aimed at preventing government from taking a larger role in the provision of medical care for the general population: Supported by the medical establishment and guided through the Senate by Senator Robert Taft, [the Hill- Burton Act] deflected President Truman's proposal for a comprehensive health plan by limiting the government's role to the subsidy of voluntary nonprofit hospitals. The Hill- Burton Act eventually helped to finance 9,200 new hospitals and other facilities, assisting in financing almost one-third of all hospital projects in the nation. (Lipscomb, 2002, p. 109) Another "fix" was the EMTALA of 1986, which required hospitals participating in Medicare that operated active emergency rooms to provide appropriate medical screening and stabilizing treatments. EMTALA was passed after several highly publicized reports of "dumping" ("the denial of or limitation in the provision of medical services to a patient for economic reasons and the referral of that patient elsewhere") despite Joint Commission on Accreditation of Healthcare Organizations (JCAHO, now The Joint Commission) and American College of Emergency Physician prohibitions, as well as the 1946 Hill- Burton Act. It is now considered one of the most comprehensive laws guaranteeing nondiscriminatory access to emergency medical care and thus to the health care system and, through interpretations by the Centers for Medicare & Medicaid Services and the courts, potentially applies to virtually all aspects of patient care in the hospital setting (Zibulewsky, 2001). The HIPAA of 1996 brought about a number of significant improvements in access to health care. HIPAA provided for improving continuity or "portability" of coverage in the large group, small group, and individual health insurance markets. It also mandated that insurance cover at least a 2-day hospital stay for women who give birth and 4 days for C-sections and that mental health have the same status as physical health. Related, but less directly, to health care access are the privacy standards established under HIPAA. The Act established that the data within the medical record belongs to the patient, whereas the physical form the data takes belongs to the entity responsible for maintaining the record. Patients have the right to ensure that the information contained in their record is accurate, and can petition their health care provider to amend factually incorrect information in their records. Finally, HIPAA created national standards for certain electronic health care transactions to improve efficiency (U.S. Department of Health and Human Services [DHHS], 2013).

Medical Specialization

*(AKA more money)* Specialization does have its advantages for patients. The high degree of knowledge and skill that specialists possess is beneficial to the patient who has a problem in that particular area of specialization. However, it also has its disadvantages. Specialists tend to focus on their specialty's organ or organ system to the exclusion of others. Some, when facing a patient, see only the organ of their own specialty, not the whole person first. The patient's overall well-being may suffer if there is no professional who can (a) see the patient as a whole person, (b) put together into one clinical picture observations derived p0225 from a variety of patient complaints arising from different organ systems, (c) guide the patient through an intelligent use of the knowledge of several specialists, and (d) set up an organized means for communication among specialists.

The Population Served

12.6% was Black or African American, 4.8% was Asian, and 10.2% was some other race, or two or more races. About 16% of the population was of Hispanic or Latino origin. As a percentage of total population, every racial and ethnic group increased between 2000 and 2010 except for non-Hispanic Whites There is also a broad range of social classes with large income differentials that are becoming wider over time Unfortunately, the United States has the greatest disparity between the rich and poor of all the Western European countries and Japan These disparities add to the complexity and fragmentation of the U.S. health care system through effects such as differential care, payment issues, cost sharing, and access problems. Age structure also affects the U.S. health care system. The population forecast for the year 2020 undoubtedly foreshadows major changes on the system, as the baby boomer generation ages. As a result, health care consumption patterns that have remained fairly constant over time will move more unevenly in the direction of elderly care. Physicians will need to spend more time providing services for the elderly, increasing from 32% of patient care hours in 2000 to 39% in 2020

Food and Drug Administration (FDA)

A federal agency charged with enforcing regulations against selling and distributing adulterated, misbranded, or hazardous food and drug products. Mission: (A) to protect the public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nation's food supply, cosmetics, and products that emit radiation. (B) to advance the public health by helping to speed innovations that make medicines and food more effective, safer, and more affordable; and to help the public get the accurate, science-based information they need to use medicines and foods to improve their health.

Centers for Medicare and Medicaid Services (CMS)

A federal agency within the U.S. Department of Health and Human Services that is responsible for Medicare and Medicaid, among many other responsibilities. Mission: To ensure availability of effective, up-to-date health care coverage and promote quality care for beneficiaries.

Local Government's Role in Health Services

A local health department (LHD) is a unit of either state or local government focusing exclusively on a "substate" geographic area, usually well-defined and considered by virtually any observer to be "local" in nature— a county, city, town, parish, or village. A current link to descriptions of LHDs nationally, as well as to descriptions of most of the major units, boards, and associations in health care, may be found at www.healthguideusa.org/ local_health_departments.htm. There is wide variation in the activities and services offered by LHDs. The activities and services most frequently offered directly by LHDs are the provision of adult immunizations (88% of departments), communicable and infectious disease surveillance (88% of departments), provision of child immunizations (86% of departments), tuberculosis screening (81% of departments), inspection of food service establishments (77% of departments), environmental health surveillance (75% of departments), food safety education (74% of departments), tuberculosis treatment (72% of departments), tobacco use prevention (70% of departments), and school and daycare inspection (68% of departments). The availability of the services varies by the size of the population served. For example, 79% of departments serving populations smaller than 25,000 people offer child immunization services, whereas 93% of departments serving more than 500,000 people do so. That the LHD does not provide a service either directly or through contract does not necessarily indicate that those services are not publically available within a jurisdiction. In some cases, another local government agency, a state agency, or a nongovernmental organization (NGO) may provide the service. Following is a brief description of some of the common public health services and programs at the local level (National Association of County and City Health Officials

PARTICIPATION

A major benefit of the proposed system will be the collection of data that essentially have been unavailable, as CDC surveillance systems have been focused on a limited number of facilities and procedures. In the current NNIS system, membership is restricted to only approximately 315 hospitals. Participating hospitals must also meet certain thresholds of bed number and size of infection control staff. Under the NHSN, all bonafide health care delivery entities (participants in the CMSs, members of the American Hospital Association, and Veterans Administration stations) whose practice generates relevant data will be encouraged to participate. Nationwide implementation of the system will be phased in, first being available to existing CDC surveillance participants, then to their affiliates, and finally to all health care entities. Nationwide availability of the system was expected sometime in 2006.

CLINICAL EFFECTIVENESS

A major concept used in defining the quality of health care in the present era is the evaluation of its effectiveness , that is, whether the care produces the desired or intended result. This term is synonymous with efficacy . Assessing the effectiveness, or efficacy, of health care at the microlevel of physician practices, hospitals, and other health care settings is becoming increasingly evidence based, that is, based on scientifically valid, empirical research. One of the best and most well-known definitions of evidence-based medicine is from an article in the British Medical Journal (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996): Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. (p. 71) Thus, the standards against which quality is measured are based on clinical research. Clinical outcomes research is the foundation of quality-improvement efforts at the microlevel. Beginning in the last decade of the 20th century, and funded by the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and other organizations, researchers have continually generated, updated, and published the results of clinical outcomes studies. These studies have then been synthesized by experts in the field, and the synthesized results are translated into clinical practice guidelines (or alternatively, clinical practice protocols). A standard definition of clinical practice guidelines was developed by Field and Lohr (1992): "systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances." Clinical practice guidelines are published by government agencies, such as the Preventive Services Task Force, and voluntary agencies, such as the medical specialty societies and the disease-specific advocacy organizations such as the American Cancer Society. Each set of practice guidelines or protocols is the result of the distillation of the evidence provided by hundreds of studies. Performance assessment and the development of evidence-based "best practices" focus on the quality of care in clinical settings, such as hospitals, ambulatory care centers, and nursing homes, for categories of disease conditions, such as heart disease, infectious diseases, diabetes, or asthma. The following abstract from a study by Carson, McDonagh, and Peterson (2006) is an example of a clinical outcomes study. It compares the effectiveness of different atypical antipsychotic drugs for people with dementia: Although the Food and Drug Administration (FDA) has not approved atypical antipsychotics for use in patients with dementia, they are commonly prescribed in this population. Recent concerns about increased risk of cerebrovascular events and mortality have led to warnings. A systematic review was conducted to assess the benefits and harms of atypical antipsychotics when used in patients with behavioral and psychological symptoms of dementia. Electronic searches (through March 2005) of the Cochrane Library, Medline, Embase, and PsycINFO were supplemented with hand searches of reference lists, dossiers submitted by pharmaceutical companies, and a review of the FDA Website and i ndustry-sponsored results database. Using predetermined criteria, each study was assessed for inclusion, and data about study design, population, interventions, and outcomes were abstracted. An overall quality rating (good, fair, or poor) was assigned based on internal validity. The evidence for olanzapine and risperidone supports their effectiveness compared with placebo. Short-term adverse events were similar to placebo. Risperidone had no advantage over haloperidol on efficacy measures in the better-quality studies. Risperidone had an advantage over haloperidol on some measures of extrapyramidal symptoms. Evidence for the other atypical antipsychotics is too limited to assess efficacy and safety. Trials were short term and conducted in highly selected populations. The potential for increased risk of cerebrovascular adverse events and mortality is a serious concern. To make judgments about when the benefits of atypical antipsychotics outweigh the potential harms, clinicians need more information. Additional data from existing trials and more complete reporting of trial results could provide this information. (p. 354) The study used as an example here is typical of evidence-based research, where the results are suggestive but inconclusive, and therefore, the implications for clinical guidelines are not certain. However, evidence-based medicine uses the results of many such studies to determine the clinical efficacy of a set of clinical practices (i.e., clinical guidelines or protocols) in order to overcome the limitations of a single study. Although clinical practice guidelines are sometimes deridingly referred to as "cookbook medicine," they are proliferating and increasingly used by insurers and other payers to evaluate the quality of medical care provided to patients.

Fixed Price

A service is called productized when it can be marketed or sold as a commodity, which implies that a fixed price will buy a known quantity of that service. Critically, the known quantity is a customer-centric outcome (or in the case of health care, treatment of a disease or condition on a per-episode basis). This can be compared with the provider-centric fee-for-service system, which focuses on what the provider does, whereas a fixed-price, productized approach is nominally focused on the condition presented by the patient. The PPS was adopted for Medicare by the federal government in 1983 for Medicare Part A benefits (i.e., payments to hospitals) as a way to control costs. It can be seen as forcing productization on the hospitals— at least with respect to the patients covered by Medicare. With PPS, the hospital is paid a predetermined rate for each Medicare patient based on the patient's presenting condition. Each patient is classified into a DRG, a preset list created by the CMS. Except for certain extremely high-cost patients, the hospital receives a flat rate for the DRG, regardless of the volume of actual services provided to a patient. CMS's DRG system historically covered only acute care and only the hospital or facility-related charges. Charges from providers received pre and post discharge, even if related to the episode of care, have been billed separately. Recently there has been a movement to bundle patient and episode-of-care payments for the most well-understood treatments such as joint replacements. In such a system the provider is rewarded for how efficiently the patient is treated. Quality is emphasized to the extent that it affects the efficiency of the treatments for the initial diagnosis. The negative side of this type of system is that it intrinsically rewards providers who exaggerate the reported severity of the diagnosis, because disease classification determines the amount of payment that will be received. Since patients are classified by the same organizations that treat them, there can be what is called "up-coding." Also, providers are rewarded for attracting or seeking healthier patients (who otherwise tend to heal faster than sicker ones) and preventive medicine tends to remain a low priority.

COMPLEMENTARY MEDICINE

A tremendous amount of out-of-pocket money is being spent by Americans each year on complementary or alternative medical care, that is, nonallopathic medicine. A growing trend in hospitals is to add complementary medical therapies to their offerings. These include acupuncture, massage therapy, guided imagery for stress reduction, pet therapy, and music/art therapy. As hospitals elbow one another to attract patients, increasingly they're hoping to tap into Americans' interest in— and willingness to spend money on— complementary and alternative therapies such as acupuncture and massage. According to a recent survey by the American Hospital Assn. and the Samueli Institute, a nonprofit research group focusing on complementary medicine, 42% of the 714 hospitals that responded offered at least one such therapy in 2010; five years earlier, only 27% of hospitals offered such treatments. Experts say hospitals are embracing these therapies for many reasons, including a growing recognition that some integrative therapies, as they're also called, are very effective in certain instances. In addition, hospitals aren't blind to the opportunity these therapies present to attract patients and perhaps make some money. According to the most recent report from the National Center for Health Statistics, Americans spent $33.9 billion on integrative therapies in 2007— with most of the money coming out of their own pockets, since the majority of these treatments aren't covered by insurance. That figure includes fees for about 354 million visits to complementary and alternative medical practitioners, and it represents about 11% of total out-of-pocket expenditures on health care. (Andrews, 2011)

Veterans Affairs Department (VA)

A veteran is defined as anyone who served 90 days or more in an armed service, but a veteran must have received an honorable or general discharge in order to be automatically eligible. The specific rules covering health care eligibility for the many classes of veterans are complex. They may be reviewed in detail on the VA website. A financial means test for certain classes was introduced by the Bush administration in 2003. The number of patients with service-connected disabilities treated in VA hospitals has been dropping over time, although with the advent of the Iraq war it is now again on the increase. The VA is the second largest federal department, with a workforce of over 327,000 employees. The VA operates the largest integrated health care delivery system in the United States and provides a wide range of primary and specialized medical care, as well as social services. Services and benefits are provided through a nationwide network of 151 medical centers, 300 veteran centers, 820 community-based outpatient clinics, 135 community living centers, 6 independent outpatient clinics, 103 residential rehabilitation centers, 139 integrated disability evaluation system sites, 131 cemeteries, and 56 regional offices. Mission Statement: "to provide veterans the world-class benefits and services they have earned - and to do so by adhering to the highest standards of compassion, commitment, excellence, professionalism, integrity, accountability, and stewardship."

HOSPITAL VERSUS AMBULATORY CARE

AHA Environmental Scan 2011 , projects that in the future: There will be widespread use of ambulatory, home and community care in place of traditional inpatient services and expanded use of new communication and monitoring techniques. Medical devices have become more portable and sophisticated, making it possible to treat and monitor chronic conditions outside the hospital. A significant number of devices including infusion pumps, ventilators and wound care therapies are now being used for home care. Given the growing number of home medical devices, the Food and Drug Administration plans on developing procedures for makers of home-care equipment. Procedures will include post- marketing follow-up and other things that will encourage the safe use of these devices. (AHA, 2011)

BIG DATA AND HEALTH INFORMATION

Access to more and better data, with the ability to manage and analyze it, will continue to transform the health care system: ■ ■ Complete, longitudinal electronic health records will allow a previously inconceivable level of data mining, enabling new levels of understanding about how genomics/biome, environment, and behavior affect health and medical care. ■ ■ Access to data will increase the emphasis on quality reporting and pay for performance, which will bring about improvements in quality of care, some improvements in costs, and eventually improvements in outcomes. ■ ■ Evaluations of medical procedure effectiveness, and resulting protocols, will continue to improve as a result of new data systems.

Mental Disorders module

Adults with any type of mental illness in the past year: 45.1 million. Adults with serious mental illness: 11 million. Published studies report that about 25 percent of all U.S. adults have a mental illness and that nearly 50 percent of U.S. adults will develop at least one mental illness during their lifetime. Nearly one-fourth of all adult stays in U.S. community hospitals involve depressive, bipolar, schizophrenia and other mental health disorders or substance use-related disorders.

Medicaid

Along with Medicare, Congress created the Medicaid program in 1965, authorized by Title XIX of the Social Security Act (C. Hoffman et al., 2001; Igelhart, 1999b; Rosenbaum, 2002). Medicaid is a needs-based program that provides coverage for some health services for some of the poor on a "means-tested" basis. Therefore, to receive Medicaid coverage, unlike Medicare coverage, a person must apply for it. Also, in contrast to Medicare, the Medicaid program then applies a series of income-level determinations to each applicant, thus "testing their means." Only those persons whose incomes and other assets fall below a certain level as specified by law or regulation (varying from state to state) are declared eligible for coverage. Medicaid is supported by federal and state tax levy funds and is administered by the states. Each state program is distinct and unique. Therefore, benefits and coverage vary widely from state to state. Like Medicare, Medicaid generally reimburses providers on a fee-for-service/episode-of-care basis, although in the mid-1990s managed care was introduced into the Medicaid program, as it was to Medicare, and each year the proportion of fee-for-service beneficiaries has been declining. Title XIX, as amended, requires a state to provide a set of 14 services in order to be eligible to receive federal funds for its program, with a very complicated set of requirements governing just who may be considered eligible for Medicaid and who may not. The 1996 Welfare Reform Act has had a major impact on Medicaid because of its elimination of the Aid to Families with Dependent Children (AFDC) program, the principal welfare program in the United States since the time of the New Deal. A combination of low income eligibility requirements and low fees paid to providers (many of whom have therefore chosen not to participate) has led to very limited coverage in many states. A few of the wealthier states now provide Medicaid coverage for the medically indigent . These are persons in an income range deemed not to be low enough to qualify them by income, but low enough to make paying for health services a heavy burden. Some states (e.g., New York) allow elderly persons with assets to divest themselves of those assets by passing them on to their children over a period of time. They can thus artificially "spend down" (by this divestiture to family members) to the stipulated Medicaid eligible income and assets levels without actually spending the money to pay for care. Of course, this means that the taxpayers of the state pick up the costs of care of a person otherwise ineligible for Medicaid. It is interesting to note that in 2011, whereas 48% of Medicaid beneficiaries were children and 27% were nonelderly, nondisabled adults (most of them the mothers of the covered children), about 63% of all Medicaid expenditures were for the benefit of the aged (21%) and the disabled (42%). Eligible elderly accounted for 10% of Medicaid beneficiaries, and eligible disabled accounted for 15%. In 2011, Medicaid covered about 16% of all personal health care spending, with over 68 million people receiving some kind of Medicaid coverage.

Summary

Although government is heavily involved in health and health care in the United States, politics and the economic system significantly limit the degree of that involvement. Government provides the legal underpinning for the system through the licensing laws. It regulates the financial workings of the system and its quality of care. It also regulates the causes of potential environmental and occupational hazardous exposures and the possible responses to them. In addition, government is a direct financier and a direct provider of service. It is preeminent in community health services and plays an important role in supporting health sciences education and research. Most health care providers of both the individual and corporate variety recognize (often grudgingly) the reality that government is already heavily involved in the health care system. As noted, they welcome participation in certain critical areas: licensing; care of the mentally ill, the tubercular, and the poor; and community health services.

MANAGED CARE

Although health insurance has traditionally been a major payer of health care costs, the enactment of the HMO Act of 1973 brought about a major change in how health insurance pays for health care, called MC . Managed care plans are health insurance plans that contract with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan's network. How much of your care the plan will pay for depends on the network's rules. Restrictive plans generally cost you less. More flexible plans cost more. There are three types of managed care plans: ■ ■ Health Maintenance Organizations (HMO) usually pay for care only within the network. You choose a primary care doctor who coordinates most of your care. ■ ■ Preferred Provider Organizations (PPO) usually pay more if you get care within the network, but they still pay a portion if you go outside. ■ ■ Point of Service (POS) plans let you choose between an HMO or a PPO each time you need care (MedlinePlus, 2011). MCOs enter into contracts with hospitals, physicians, and other providers to deliver health care to their enrollees (or beneficiaries) at what the MCO believes will be a favorable rate per enrollee for their care (capitated). Key attributes of MC plans are (a) selecting providers who will then deliver a comprehensive range of services to enrollees at the agreed upon rate; (b) giving economic incentives to providers to choose less costly care; and (c) reviewing providers' utilization and quality of care, formally and regularly, through data mining claims data and chart review. Typically, the primary care provider is the "gatekeeper" who must approve the use of specialists. There are controls on inpatient hospital care and length of stay; and disease management, case management, wellness incentives, and patient education are used to control costs and quality. This matter-of-fact description of MC disguises the transformational change that it brought about in the U.S. health care system. MC shifted the balance of power from providers to payers. Payers entered "the treatment room" with providers, influencing their treatment patterns through reimbursement rates that affect patient flow; through provider incentives that favor certain tests and procedures over others; and through utilization and quality reviews that further constrain provider autonomy in decision making. MC has been a very controversial practice from the start. Critics say it restricts needed access to health care and adversely affects health care quality. The use of economic incentives to providers for limiting certain kinds of health care and the restraint on their fees concern detractors. Proponents argue that MC reduces inefficiencies and, thereby, costs of the health care system without affecting quality or access. However, two factors make it difficult to evaluate the effects of MC on cost, quality, and access. First, MC is almost invisible now because it is so pervasive. All payers— for-profit, nonprofit, and government— have adopted MC principles and practices to some extent. As an example, the health care reform legislation passed under President Obama in 2010— the Affordable Care Act— put MC principles and practices into place by its focus on effectiveness and efficiency. Second, MC plans are so varied that it is difficult to generalize about their effects on cost, quality, and access. The criteria for selection of providers, the limitations on covered services, the reimbursement rates negotiated with providers, and the ways that utilization and quality reviews are used differ widely across plans. Thus, we should expect that the actual quality of care received and the costs of that care will differ, as well. These factors— reimbursement rates, favored services, and utilization review criteria— may be more predictive of quality and cost of health care than whether or not the care was "managed." Nevertheless, we refer to MC because of its singular influence on the way health care is delivered today in the United States, although its influence on costs, quality, and access appears not to be uniform.

INFORMING CLINICANS

Although using EHRs promotes quality and efficiency in health care settings, few health care organizations and practices in the United States have computerized their medical records as of the writing of this book. Acceptance is growing, and many hospitals, in particular, have or are obtaining EMR systems. However, most small practices still use paper records exclusively. The ONC has identified several reasons for the slow adoption of EHRs among health care organizations and practices, including the cost of hardware, software, and training and disruption of the present workflow. Therefore, one goal of the ONC is to arrange for the investment in EHRs to be shared between clinicians and others in the health care system. The office is exploring financial and nonfinancial incentives for investors. Second, the ONC will certify EHR software vendors to help clinicians choose vendors with standard products. Third, the ONC will develop a strategy to provide access to EHRs in rural and underserved areas.

Health Statistics

Among the oldest of public health functions is the collection and analysis of vital and health statistics. Data on births, deaths, marriages, and divorces (the "vital" statistics), and incidence of the several reportable (primarily infectious) diseases, are collected by the local health authorities and forwarded to the state level. There they are codified and analyzed, often by various demographic characteristics, such as age, gender, marital status, ethnicity, and geographic location. Each state then forwards its collected data to the NCHS of the CDC for further analysis and publication.

Patterns of Practice

An important feature of medical practice organization in the United States is that most physicians see patients both on an ambulatory basis and as hospital inpatients. (A small percentage of doctors do not have hospital appointments. Another small percentage belongs to the growing subspecialty of "hospitalist," physicians who, usually working for the hospital, see only hospitalized patients; also see the later discussion.) In most other countries, physicians either see ambulatory patients only or work full time in hospitals. In the United States, ambulatory care is the predominant setting for medical care. Most ambulatory care visits are in physician offices.

Medical Education

An unusual aspect of the U.S. medical education is that a significant number of U.S. citizens are trained to be physicians in offshore, for-profit medical schools, established for the purpose of providing places for at least some of those applicants to the U.S. schools who cannot gain entry to them. These offshore schools are not recognized by the LCME.

PATEINT SAFETY

Another aspect of health care quality is patient safety. The patient safety movement of the 1990s led to a great deal of interest in improving the quality of health care delivery through the application of methods borrowed from other industries and pioneered by W. Edwards Deming. Deming was an American statistician, considered the father of the modern quality assurance movement. He developed his system following the end of World War II. Unable to get a hearing in this country, he went to Japan. His methods, designated Statistical Process Control (SPC) and Total Quality Management (TQM), strongly influenced the rebirth and eventual massive expansion of Japanese industry post- World War II. Patient safety has been defined by the Institute of Medicine (2000) as "freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur" (p. 211). Therefore, patient safety encompasses all events and situations that result in accidental harm to patients, including medication errors, surgical mistakes, falls, improper use of medical devices, and nosocomial infection. The Institute of Medicine report, To Err Is Human (2000), has played a major role in bringing national attention to the issue of patient safety. The Report converted an issue of gradually growing professional awareness over a great deal of time to one of substantial public concern in a manner and pace unprecedented in modern experience with matters of healthcare quality. The epidemiologic finding that more than one million injuries and nearly 100,000 deaths occur in the United States annually as a result of mistakes in medical care came from studies nearly a decade old. But this was new information for the public, and it resonated strongly. (Leape, Berwick, & Bates, 2002, p. 501) To Err Is Human brought a new perspective to health care quality assurance by supporting the importation of industrial quality-improvement practices into health care settings. Using Charles Perrow's analysis of the Three Mile Island accident (Perrow, 1984) as a model, the report advocates a systems approach to health care improvement in order to understand and modify the conditions that contribute to errors. The authors conclude (Institute of Medicine, 2000): The application of human factors in other industries has successfully reduced errors. Health care has to look at medical error not as a special case of medicine, but as a special case of error, and to apply the theory and approaches already used in other fields to reduce errors and improve reliability. (p. 66) There are many excellent books on the application of health improvement methods to health care, including the classic by Berwick, Gladfrey, and Roessner (1990) and the more recent by Dlugacz, Restifo, and Greenwood (2004). A number of organizations provide training in quality-improvement methods. Hospitals that have applied these quality- improvement methods have reported significant success in improving safety (e.g., Van den Heuvel, Bogers, Does, van Dijk, & Berg, 2006).

Anxiety Module

Approximately 40 million American adults ages 18 and older, or about 18.1 percent of people in this age group in a given year, have an anxiety order. Anxiety disorders frequently co-occur with depressive disorders or substance abuse. Nearly three-quarters of those with an anxiety disorder will have their first episode by age 21.5. Statistics are not yet available for mental health during the pandemic, but increases in self reported anxiety have increased dramatically.

Health Services Financing

As will be described in more detail in Chapter 5, government participates in the financing system in three ways. First, it pays for the operation of its own programs, both personal and community. It does this directly, for example, through the federal government's Veterans Affairs (VAs) hospital system or a municipal hospital serving primarily the poor. It also does this indirectly, for example, through the federal government's provision of grants to state governments to help pay for personal care in state mental hospitals and for the operation of the state's public health agencies at the community level. The states, in turn, indirectly support local governmental public health activities by providing money for that purpose. Second, through grants and contracts to nongovernmental agencies (and, in certain cases, other governmental agencies), governments support other types of health-related programs, for example, in biomedical research and medical education. Third, and this is by far the major role of government in financing, under such programs as Medicare and Medicaid, governments pay providers for the delivery of care to patients. As will be discussed in greater detail in Chapter 5, federal, state, and local public funds accounted for about 43.4% of national health expenditures in 2013, up from 35.5% in 2000 and 32.6% in 1990. Concomitantly, private business' contribution to the national health expenditures dropped from 24.6% in 1990 to 20.9% in 2013, and the household contribution declined from 34.9% in 1990 to 28.2% in 2013 (National Center for Health Statistics [NCHS], 2015, Table 109).

The Legislative Branch

At each level of government, federal, state, and local, the three branches of government have responsibility and authority for health and health services. Legislatures create the laws that establish the means to safeguard the public's health, in matters ranging from the assurance of a pure water supply to protecting the health of workers in their places of employment. The legislatures also enact the legal framework within which the health care delivery system functions, determining which individuals and institutions are authorized to deliver what services to which persons under what conditions and requirements. In the past, legislatures have imposed certain requirements for planning and development on the system, although in most jurisdictions that function has been minimized or has disappeared entirely. If the government is to participate in health care financing (see Chapter 5), directly deliver services, or support research efforts, the legislature must first establish the legal authority for those programs.

State Government's Role in Health Services

At the state level many different agencies are involved in health services. For example, in most states, departments other than the health department provide two of the important health-related functions managed primarily by the states: mental illness treatment services and Medicaid operations. Furthermore, the licensing authority for health personnel sometimes resides in the education department, vocational rehabilitation is often found in a special agency, occupational health in the labor department, environmental protection in a separate department, and school health with local boards of education. Most states also have a board of health, usually appointed by the governor, which has varying administrative, policy, and advisory functions. In the 1920s, political struggles with private practitioners led to a limitation of service responsibilities for both the state and local health departments (LHDs). Haven Emerson, a leading public health official of the time, defined the "Basic Six" services appropriate for departments of public health: vital statistics, public health laboratories, communicable disease control, environmental sanitation, maternal and child health, and public health education (Wilson & Neuhauser, 1976, p. 204). Some time ago, the Association of State and Territorial Health Officials (ASTHO) defined a state health program as [a] set of identifiable services organized to solve health related problems or to meet specific health or health related needs, provided to or on behalf of the public, by or under the direction of an organizational entity in a State Health Agency [SHA], and for which reasonably accurate estimates of expenditures can be made. (ASTHO, 1980, p. vii) Using this definition, ASTHO identified six program areas for SHAs: "personal health, environmental health, health resources, laboratory, general administration and services, and funds to LHDs not allocated to program areas" (ASTHO, 1980, p. 9). Although the number has stayed the same, in some states the content of the work has expanded well beyond that covered by the "Basic Six" (Dandoy, 1996). In 2012, the ASTHO General Policy on Public Health (ASTHO, 2012) stated: p0360 Public health is what we, as a society, do collectively to assure living conditions in which people can be healthy. Federal, state, territorial, and local governmental agencies working with public and private entities comprise the nation's public health system. Collectively, the system prevents disease, injury, and disability; protects against environmental hazards; promotes physical and mental health; responds to disasters and emerging diseases; and ensures access to health care services. Within this broader public health system, governmental public health— composed of federal, state, and local health agencies— occupies an exceptional and fundamental role. It is uniquely accountable to the public and elected representatives for the responsible use of tax dollars that fund its activities. The U.S. Constitution reserves to the states the primary authority and legal responsibility to protect the health of the population within their borders. Still, no single component of the government's public health system can function to maximum effectiveness without the other two. The governmental public health system is successful if it fulfills its unique federal, state, territorial, and local roles and effectively collaborates with government agencies and the private sector. Of note in this most recent ASTHO policy statement is the emphasis on evidence-based public health, that is, holding the public health system accountable for implementing sound practice and evidence-based methods that address public health problems effectively and efficiently. Since World War II, as the health care delivery system has become vastly more comp0380 plex, there has been an increasing number of public health and health services interests requiring protection. In response, governments have vastly expanded the responsibilities of both state and local departments of health and other health-related governmental agencies. Those responsibilities now include, for example, regulation and quality assurance for physicians, hospitals, other provider agencies and groups (including institutional licensure) planning (what there is of it) ever more complex environmental protection functions and, of course, regulation of payers. As noted earlier, it is interesting just how much government regulation of the health care system there is in the United States, well beyond that found in other countries. This is precisely because there is no national health system, so in order to provide some modicum of protection to the public in terms of finance and health care quality, the various players must be regulated. As also noted previously, state and local health-related activities outside the health departments have expanded, as well.

Capitation

Capitation is a fixed prepayment per person to the health care provider for an agreed-on array of services. The payment is the same no matter how many services or what type of services each patient actually gets. In theory, such a system encourages the selection of the least expensive treatments as well as promotes services likely to result in the lowest overall cost during the contract period. However, such a system has no reinforcement for promoting the long-term health of the patient. With capitation, providers are likely to be rewarded for enrolling patients least likely to consume many health services, that is, the healthy. One can also see global budgeting (a payment method common to government-run facilities) as a simplified form of capitation— one with only one payer. The provider receives a global budget, which must cover all costs of treatment needed by the eligible population. This is the common way of paying for Veterans Administration hospitals, state mental hospitals, and local health department clinics. In practice, a global budget model tends to resemble the cost model, as the budgets are often negotiated starting with the previous year's cost, and those in operational control are not usually rewarded for coming in under budget (in bureaucracies, coming in under budget is taken as a sign that the budget was set too high).

Long-Term Care

Chronic problems with the quality of long-term care provoke periodic exposés and outcries for reform (Eisen & Sloan, 1997; Pear, 2002). However, because any institutional care is expensive, the long-term solution to the long-term care problem probably lies with improved home-care services and significantly improved health promotion, disease prevention, and self-care programs for the rapidly increasing number of elderly persons in the United States. Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail.action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 11:18:23.

Components of the U.S. Health Care System 2(Modules)

Components of U.S. Health Care System: Using the WHO definition as a building block consider the components of the U.S. Health Care System identified in your text. 1. Facilities where health care is provided 2. Workforce that provides services 3. Health Care Training and Research 4. Suppliers of medical/healthcare products 5. Financing mechanisms

CONSOLIDATION WITHIN THE HEALTH CARE SYSTEM

Consolidation will be an ongoing theme, continuing the trend of the past 20 years. As the Commonwealth Fund report notes: It seemed like every week in 2015 brought news of a mega-merger between two drug companies, hospital systems, or health insurers. This arms race in market size has attracted scrutiny from regulators and calls for greater antitrust enforcement. Such calls are likely to grow louder in light of new evidence linking high regional private health spending to market concentration, and indications that competition in insurance markets lowers premiums. (Blumenthal & Squires, 2015) Consolidation will take place across three dimensions: ■ ■ Vertical with payers and providers ■ ■ Horizontal with the creation of larger systems ■ ■ Continuum of care from primary care through post acute care

Chips

Created as the State Children's Health Insurance Program by the Clinton Administration's Balanced Budget Act (BBA) of 1997, the Children's Health Insurance Program provides health coverage for uninsured children who are not eligible for Medicaid. It is jointly financed by the federal and state governments and administered by the states. Within broad federal guidelines, each state determines the design of its program, eligibility groups, benefit packages, payment levels for coverage, and administrative and operating procedures. SCHIP provides a capped amount of funds to states on a matching basis for federal fiscal years (FYs) 1998 to 2007. Federal payments to states are based on state expenditures under approved plans. "Though an optional program, all states expanded coverage under SCHIP, with an estimated 6.7 million children and 700,000 adults enrolled in SCHIP at some point during 2006"

Primary Care Historical Background

Despite these recommendations, in the United States, as physician specialization and subspecialization increased dramatically in the period following World War II, much of the ambulatory care provided in private offices and groups and in hospital outpatient departments became highly fragmented (Freymann, 1974). The need to restore continuity and coordination was recognized in the 1960s and led to a revitalization of the primary care concept Many of the health services entities called neighborhood health centers that developed in the 1960s and 1970s fostered the primary care approach, as did many of the original health maintenance organizations developed in the 1970s and 1980s. Nevertheless, in the 1990s, it was still the case that most people in the United States did not have access to comprehensive primary care, even with insurance.

Employer-Based Health Insurance

During the first decades of the 20th century, the value of medical care was becoming evident in vaccines and antitoxins, which prevented childhood illnesses; medicines, such as insulin, which saved and extended life; and surgery, which could cure dozens of conditions, aided by effective anesthesia and the protection of aseptic techniques. It was at that point that reformers sought to extend the reach of professional medical attention to the entire population for the first time. International comparisons in rates of illness and death, which became possible with the standardization of vital statistics reporting, again emphasized the dramatic differences in both overall death rates and in deaths from specific causes as a result of public health improvements and medical care (Center for Medical Humanities, Compassionate Care, and Bioethics, 2012). In response, the United States created a system of employer-based health insurance for nonmilitary workers and their families. In 1910, early forerunners of health insurance plans (HIP) appeared as "prepaid" group practices. Plan members paid a monthly premium and received a wide range of medical services through an exclusive group of providers. The American system of health insurance developed from there. In 1929, Blue Cross Plans were established to provide "prepaid" hospital care to workers in the Dallas public school system: An official at Baylor University Hospital in Dallas noticed that Americans, on average, were spending more on cosmetics than on medical care. "We spend a dollar or so at a time for cosmetics and do not notice the high cost," he said. "The ribbon-counter clerk can pay 50 cents, 75 cents, or $1 a month, yet it would take about 20 years to set aside [money for] a large hospital bill. The Baylor hospital started looking for a way to get regular folks in Dallas to pay for health care the same way they paid for lipstick— a tiny bit each month. Hospital officials started small, offering a deal to a group of public school teachers in Dallas. They offered a plan for the teachers to pay 50 cents each month in exchange for Baylor picking up the tab on hospital visits. (Blumberg & Davidson, 2009) In 1930, Blue Shield Plans began providing reimbursement for physician services. In 1955, the spread of health insurance coverage— from less than 10% of the population having coverage in 1940— grew to nearly 70%. The Blue Cross and Blue Shield logos become ubiquitous icons in both homes and medical offices across America (Lichtenstein, 2015). Employer-based insurance was fostered by World War II caps on wages that led employers to lure workers with benefits such as health insurance. At the same time that employer-based insurance was being developed, the United States continued to build a military health care system for members of the armed forces, their dependents, and veterans, which was begun in the 19th century when the federal government authorized, in 1811, the first home and medical facility for veterans. Later in the 19th century, the nation's veterans' assistance was expanded to include benefits and pensions for veterans as well as their widows and dependents. The system continued to grow and develop and is a major provider of health care today (U.S. Department of Veterans Affairs [VA], 2015). very small employers (3- 9 workers) and 73% of small employers (10- 24 workers) did so (Kaiser Family Foundation, 2006). It is noteworthy that the overall insured rate dropped from 69% in 2000 to 61% in 2006, because of a decline in the number of the smallest firms to offer health insurance to their employees. Additionally, whereas more than 29% of the "jumbo" firms (5,000 + workers) offered a choice of plans, fewer than 10% of small employers (3- 199 workers) did so (Kaiser Family Foundation, 2006). Also of note is that the percentage of jumbo firms offering only one plan increased from 7% in 2000 to 29% in 2006.

Identify common structures of hospitals

Each hospital's structure will follow based on the scale and different lines of business. A small, acute care hospital with half a dozen nursing units will necessarily have a different structure than a large, multistate integrated delivery system. Most commonly, hospital departments will fall into a few divisions: ■ ■ Administration: including common corporate functions, such as finance and human resources ■ ■ Nursing: clinical departments such as inpatient nursing units ■ ■ Ancillary services: other clinical departments, such as cardiology and radiology, which may serve a mix of inpatients and outpatients ■ ■ Support services: facility services such as plant maintenance, housekeeping, and food service ■ ■ Outpatient services: typically ambulatory clinics and other outpatient-only departments. By Joint Commission standards, there should be three leadership groups: a governing body (typically a "board of directors"), a chief executive and other senior managers (often referred to as the "C-suite"), and the leaders of the medical staff. The medical staff should be both accountable to the governing body as well as self-organizing. Beyond that, Joint Commission standards require a chief nursing officer to whom all nurses have at least a dotted-line reporting relationship. Practically speaking, the organization must have a designated chief financial officer and supporting finance function. Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail.action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 10:32:29.

EQUITY OF HEALTH CARE

Equity is the second criterion used to evaluate the performance of health care systems. Equity or distributive justice is concerned with the fair allocation of benefits and burdens among those who are deserving of care and those who are in a position to pay for it— the two groups may or may not be the same (Aday et al., 1993, p. 120). We are concerned about inequities in access to health care as well as inequities in the quality of health care— as measured and evaluated by standards established for structure, process, and outcomes. We use disparities in access and quality of health care to indicate inequity. The factors that are consistently associated with inequities in health care access and quality are socioeconomic status (SES), race and ethnicity, and geographic location. We find in study after study that people with low income, low education, and low-status occupations; people belonging to minority racial and ethnic groups, particularly African American and Hispanic; and people who live in rural areas or inner cities are more likely to have poor access to care and poor-quality health care (Institute of Medicine, 2003).

DATA AND INFORMATION TECHNOLOGY

Every major organization with an interest in health care performance recognizes the need for better data in order to benchmark the current situation and then determine whether improvements have occurred in quality, access and equity, and cost and efficiency. These organizations include the payers for health care, such as the Medicaid and Medicare programs and private health insurance companies; providers of health care, including hospitals; private foundations, such as the Robert Wood Johnson Foundation, with a focus on health policy; the public- private partnerships such as the NQF and JCAHO; and many consumer groups such as Consumers Union, which has an interest in nosocomial infection control. It is generally agreed, as Hanrahan and his colleagues write, "Proper functioning of health care systems requires an advanced health information network that supports clinical care, personal health management, population health, and research. But this infrastructure does not yet exist in the United States" (Hanrahan, Foldy, Barthell, & Wood, 2006, p. 16). The health information systems needed to evaluate performance are both internal to health care organizations and external between health care organizations. The latter are called regional health information organizations or RHIOs. The electronic medical record (EMR) or electronic health record (EHR) is one of the basic sources of data for internal health information systems, as well as for RHIOs, but both types of systems will include other data as well. These systems will be used to (a) conduct clinical outcomes studies; (b) measure population health outcomes, such as morbidity and mortality rates for regions, states, and the nation; (c) design and evaluate interventions to improve clinical practice; and (d) increase access, equity, and efficiency.

Hospital Outpatient Departments

For a variety of reasons, most American hospitals traditionally have focused the bulk of their efforts and activities on inpatients who are acutely ill and confined to bed (Freymann, 1974). However, hospitals also have had to deal with other types of patients, with most classified as "outpatients." Hospital outpatients require either immediate treatment for an acute and sometimes serious illness or injury, or ongoing care for a more routine matter. Very often the services of the latter type are similar to those needed by patients who attend physicians' offices. In theory at least, there are two categories of hospital ambulatory services, corresponding to the two principal categories of patient needs: emergency services, provided by emergency rooms or EDs, and clinic services or OPDs. In the real world, overlap between the two categories of service is increasing. Patients, hospital staff, and hospital administrations, separately and together, are sometimes confused about the differences in role and function of the two categories. All three groups sometimes have trouble deciding which patients should go where for what. The original intended functions of hospital emergency service units were (a) to take care of acutely ill or injured people, particularly with life-threatening or potentially life-threatening problems that required immediate attention by personnel, or equipment not found in private practitioners' offices and (b) to offer prompt hospitalization if needed. Most hospitals have found it desirable or necessary (legally required in many states) to provide such services. In the past, it was easier for hospitals to determine that emergency services should be provided than that clinic services should be. One reason for this was that insurance companies were more likely to reimburse hospitals for emergency services than for clinic services. Under managed care, and with the steadily increasing number of Americans who have no or inadequate health insurance coverage, this situation is changing. In fact, the use of EDs for non preapproved, nonurgent care by MCO beneficiaries has created a major cost-containment problem for the managed care industry. In an increasing number of instances, the MCO is refusing to pay the hospital for such care. IN 2007 approximately 89 million visits were made to the hospital OPD. The 10 most common reasons for visits were progress visit (follow-up to previous visit), general medical exam, routine prenatal examination, cough, medication, symptoms referable to the throat, postoperative visit, hypertension, well baby examination, and stomach pain, cramps, and spasms. Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail.action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 12:08:53.

Determinants of Health

Genetic Inheritance, Physical Environment, Social Environment, and Health Behavior.

Provision of Personal Health Services

Government at all levels is the major provider of the traditional community-wide "public health" services, such as pure water supply and sanitary sewage disposal, food and drug inspection and regulation, communicable disease control (e.g., immunization and the control of sexually transmitted diseases), vital statistics, environmental regulation and protection, and public health laboratory work. Certain community health activities are shared with the private sector. For example, in public health education, voluntary agencies such as the American Cancer Society and the American Heart Association are important participants. Private refuse companies do much of the solid waste collection and, in certain states, supply the water. Private organizations such as the Sierra Club and the Natural Resources Defense Council are active in environmental protection. Private institutions also play a vital role in health sciences education and research.

Government Spending on Health Care

Government spending has accounted for an increasing proportion of the health care dollar since 1960 (see Table 5.3). At that time, 5 years before Congress enacted the Medicare and Medicaid programs, the government's share was about 23% of the total. By 1970, it was 37% and by 1980 it was almost 42%. In 2009, local, state, and federal programs covered about 49% of national health care consumption. The vast majority is through the Medicare and Medicaid programs

How much is Spent

Health care spending has increased in the United States every year since 1960 in both absolute and relative terms (Table 5.1). Between 1980 and 2013, per capita spending on health care increased by more than a factor of 8. In 1980, health care expenditures accounted for only 8.9% of the GDP, in contrast to 17.4% of the GDP in 2013. During the 1980s, the annual rate of increase in health care expenditures was constantly in the double-digit range, even when inflation and the GDP growth rates were not. Why this happened is a matter of much controversy. Starting in the 1990s, with the advent of managed care and its downward pressure on both physician and hospital usage, a brake was put on health care cost increases, at least for several years: The rates of increase from 1970 to 1990 had been over 10% per year (see Table 5.1). Between 1990 and 2000, the rate fell from 11% to 6.6%, and then began an upward climb again. Starting in 2003, NHE growth rates slowed every year through 2009, when spending grew at only 3.8%. In 2013, per capita health spending increased by 1.5% similar to growth in the preceding 3 years as overall health spending growth has matched economic growth in recent years. This is in contrast to the rapid increases recorded in the 2000s when health expenditure grew on average by around 3.6% per year and out spaced economic growth by more than three times (Organization for Economic Cooperation and Development [OECD], 2015). A considerable part of the constant upward trend in health care spending in the United States has been caused by factors other than simple utilization, such as the every -intensifying use of expensive technology-based diagnostic and procedural interventions, especially at the beginning and the end of life (Franks, Clancy, & Nutting, 1992; Meier & Morrison, 2002). In "The Growth in Cost Per Case Explains Far More of U.S. Health Spending Increases Than Rising Disease Prevalence," Roehrig and Rousseau (2011) show that three quarters of the increase in real per capita health spending was attributable to growth in cost per case. Thus, it remains to be seen how long the increase in expenditure rate will remain at a relatively modest level (although still above the general rate of inflation), or whether it will return to its previously astronomical (double-digit) levels, as in the 1970s and 1980s.

Neighborhood and Community Health Centers

Health centers are characterized by five essential elements that differentiate them from other providers (HRSA, 2012): ■ ■ They must be located in or serve a high-need community, that is, "medically underserved areas" or "medically underserved populations." ■■ They must provide comprehensive primary care services as well as supportive services, such as, translation and transportation services that promote access to health care. ■ ■ Their services must be available to all residents of their service areas, with fees adjusted upon patients' ability to pay. ■ ■ They must be governed by a community board with health center patients constituting a majority of members. ■ ■ They must meet other performance and accountability requirements regarding their administrative, clinical, and financial operations. Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail.action?docID=4558160. Created from stclaircc-ebooks on 2021-02-12 12:21:01.

POPULATION HEALTH OUTCOMES

Health outcomes can be measured at the population level and used to evaluate the quality of a health care system (Kindig, 1997). Population health indicators include population mortality and morbidity rates. These are used in macrolevel performance evaluations of regions, states, and nations. We assume the impact of health care on these rates even though we are not directly measuring use of health care among the population considered. If, for example, a disease-specific mortality rate is higher in one region than another, we assume that the health care system has not been optimal in the region with the higher mortality rate. Historically, population health indicators have been age-adjusted death rates, disease-specific death rates, life expectancy, premature death rate, time lost to prema ture death, and infant mortality rate (IMR). 1 The United Nations International Children's Emergency Fund (UNICEF) defines IMR as the probability of dying between birth and exactly 1 year of age (UNICEF, 2006). This rate is expressed per 1,000 live births per year. IMR is an important measure that indicates the well-being of infants, children, and pregnant women, as it is associated with maternal health, quality, and access to care, and public health in a given population. Life expectancy is defined by the World Health Organization (WHO) as the number of years of life that can be expected, on average, in a given population. Using life expectancy, the premature death rate can be calculated. The premature death rate is the death rate for persons who die before the expected age of death for that population. The time lost to premature death, also called years of potential life lost (YPLL), is based on the difference between the actual age at death and the expected age at death. Deaths at a younger age are weighted more heavily in the YPLL, providing an indicator of the severity of premature death's impact on the population (WHO, 2012a). A more recent concept of population health takes into account quality of life. Healthy life expectancy (HALE) at birth is defined by WHO as the "average number of years that a person can expect to live in 'full health' by taking into account years lived in less than full health due to disease and/or injury" (WHO, 2012c, p. 1). HALE is a measure that combines length and quality of life into a single estimate that indicates years of life that can be expected in a specified state of health (Kindig, 1997, p. 45). Other health-adjusted life expectancy measures are quality-adjusted life years (QALYs), which emphasizes the individual's perceived health status as the indicator of quality of life; disability-adjusted life years (DALYs), which combines mortality and disability measures; and years of healthy life (YHL), which combines perceived health and disability activity limitation measures from the National Health Interview Survey (Kindig, 1997). Health outcomes can be measured at the population level and used to evaluate the quality of a health care system (Kindig, 1997). Population health indicators include population mortality and morbidity rates. These are used in macrolevel performance evaluations of regions, states, and nations. We assume the impact of health care on these rates even though we are not directly measuring use of health care among the population considered. If, for example, a disease-specific mortality rate is higher in one region than another, we assume that the health care system has not been optimal in the region with the higher mortality rate. Historically, population health indicators have been age-adjusted death rates, disease-specific death rates, life expectancy, premature death rate, time lost to prema ture death, and infant mortality rate (IMR). 1 The United Nations International Children's Emergency Fund (UNICEF) defines IMR as the probability of dying between birth and exactly 1 year of age (UNICEF, 2006). This rate is expressed per 1,000 live births per year. IMR is an important measure that indicates the well-being of infants, children, and pregnant women, as it is associated with maternal health, quality, and access to care, and public health in a given population. Life expectancy is defined by the World Health Organization (WHO) as the number of years of life that can be expected, on average, in a given population. Using life expectancy, the premature death rate can be calculated. The premature death rate is the death rate for persons who die before the expected age of death for that population. The time lost to premature death, also called years of potential life lost (YPLL), is based on the difference between the actual age at death and the expected age at death. Deaths at a younger age are weighted more heavily in the YPLL, providing an indicator of the severity of premature death's impact on the population (WHO, 2012a). A more recent concept of population health takes into account quality of life. Healthy life expectancy (HALE) at birth is defined by WHO as the "average number of years that a person can expect to live in 'full health' by taking into account years lived in less than full health due to disease and/or injury" (WHO, 2012c, p. 1). HALE is a measure that combines length and quality of life into a single estimate that indicates years of life that can be expected in a specified state of health (Kindig, 1997, p. 45). Other health-adjusted life expectancy measures are quality-adjusted life years (QALYs), which emphasizes the individual's perceived health status as the indicator of quality of life; disability-adjusted life years (DALYs), which combines mortality and disability measures; and years of healthy life (YHL), which combines perceived health and disability activity limitation measures from the National Health Interview Survey (Kindig, 1997).

CLINICAL OUTCOMES

Health outcomes that are specific to the persons who receive care are often called clinical outcomes . We frequently use the following outcome measures in studies of health care quality among patients: readmission to the hospital after a surgical procedure; functional capacity after medical intervention; long-term pain and discomfort after medical treatment; infection acquired during a hospital stay (nosocomial); 5-year mortality rates among patients treated for cancer, heart disease, or other diseases; development of comorbidities after medical therapy; and satisfaction of the patient with the outcomes of health care treatment. Clinical outcomes research is the term given to studies that focus on the persons who receive care (patients) and the outcomes of their treatment. Following is a discussion of health care quality at the microlevel of clinical outcomes. We examine two aspects related to microlevel evaluation of health care quality: clinical effectiveness and patient safety.

Home Care and Hospice Care

Hospice care is defined as a program of palliative and supportive care services that provides physical, psychological, social, and spiritual care for dying persons, their families, and other loved ones. Hospice services are available in both the home and inpatient settings. In 2010, there were 33,000 providers in the United States and 10,581 Medicare certified home care agencies. Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail.action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 11:24:26.

Discuss who impacts direction, control and governance of hospitals: Modules

Hospitals have three main entities that influence their direction, control, and governance: The Board of Trustees is ultimately responsible for all of the activities of a hospital. It is their job to set policy, hire an administrator to carry out that policy, and approve all physician admitting privileges. In addition, they play a large role in developing political and community liaisons. Administration carries out all policies and manages the hospital in accordance with all regulations in a safe, efficient, and cost-effective manner. The medical staff admits patients to the hospital and then orders/performs tests/procedures using hospital services. These test/procedures may also be done in an outpatient setting. Obviously without patients, a hospital does not need to exist, so patients are extremely important. In addition to the above components, hospitals employ many people for a variety of services. In fact, hospitals are usually a major employer in any community. For example, McLaren Port Huron Hospital is the second largest employer in Port Huron. Therefore, a hospital is very important to communities both as an employer and for economic survival when those employees spend their pay checks.

Physician Supply Model

In 2012, about 785,000 (> 95%) of all physicians worked in patient care. Of those, 75% were in office-based practice, about 15% were house staff (residents in training), and more than 10.5% were fully qualified physicians working full time in hospitals about 26% of the active MDs received their medical training outside the United States and Canada.

Physicians

In 2012, the American Medical Association (AMA) reported 826,001 active physicians (those with an MD degree) (NCHS, 2015a, Table 93). The ratio of other health personnel to physicians reflects the complexity of the U.S. health care system. With close to 826,000 physicians in active practice, there are more than 19 other health care workers for each physician. In 1988, there were close to 18 other health care workers for each physician. This compares to about three other health care workers per doctor in 1920 (Donabedian, Axelrod, & Wyszewianski, 1980). Most of these other personnel have skills learned through special training. Only about one fifth is "nonhealth care"—specifically clerical, custodial, or similar personnel.

Ambulatory Care Utilization

In 2012, there were 928 million ambulatory patient visits to office-based physicians. Americans averaged 3.0 physician visits per person (NCHS, 2013, Table 1). Women made up 58.2% of all physician office visits, although men visited more than women for injury-related conditions in every age group 45 to 65 years and under (NCHS, 2013, Table 3). After age 65, women made more visits than men in each age group (NCHS, 2013, Table 14). Women made more visits than men at every age group except 75+ (Table 2.3). In 2012, the most frequent primary diagnosis in the ambulatory care setting was routine infant or child health check (37.5 million visits or 46.3 million visits or 4% of the total). This was followed by essential hypertension and arthropathies and related disorders (NCHS, 2013). Table 2.4 contains the leading 20 primary diagnoses for office visits. Now, we briefly discuss the various ambulatory settings other than the physician office, chief among them the hospital outpatient department (OPD). Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail.action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 11:46:54.

Provider Payment Approaches

In the health care market, professional services from physicians, therapists, dentists, and so forth accounted for 27% of Health Care Consumption in 2013 (see Table 5.2). These providers are also considered to drive the utilization of much of the remainder of NHE, including hospital care, nursing home and home health care, prescription drugs, and medical equipment, devices, and supplies. Prescription drugs and other medical products are also markets with their own dynamics, but this discussion focuses on how the services of health care providers and institutions (e.g., hospitals, nursing homes) are paid. In general, there are six payment modes that people and organizations use to buy and sell services. These are cost/cost-plus, hourly or time and materials, fee-for-service, fixed price, capitation, and value. We discuss each in relationship to the provision of personal health care services.

School Health Clinics

In 2013, there were more than 77.8 million students in primary and secondary schools, colleges, and universities, both private and public. More than 41 million were enrolled in primary schools and 16.6 million in secondary schools (U.S. Census Bureau, 2013, Table 1). Almost all educational institutions provide some type of organized, ambulatory health service. About half of the school health services are run by local health departments, the balance being run by boards of education, on their own or in cooperation with the local health department. Very little disease treatment is done in school health programs. Usually carried out by school nurses, the work of most of these programs is confined to case finding and prevention for certain chronic or epidemic diseases, for example, screening for vision and hearing difficulties and providing immunizations. Referrals are made to physicians for diagnosis and treatment, should they be indicated. College and university health services are more likely to provide general diagnostic and treatment care. Some pay special attention to mental and substance abuse problems. This is changing in some schools because of increasing numbers of children with chronic diseases, such as asthma and diabetes, who frequently need medical attention during the day Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail.action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 12:30:10.

LEGISLATIVE INITIATIVES

In addition to the federal, private, and private- public efforts just discussed, state legislatures have become involved in quality health care issues. For example, several states have passed or have pending legislation that mandates hospitals to disclose their infection rates to the public. The rationale behind these initiatives is that hospitals will improve their infection control programs if threatened by the loss of patients or purchasers to competitors who seem to have better infection control performance than their own. (As the old saying goes, "sunlight is the best disinfectant.") Pennsylvania and Illinois were leaders in this area. Following widely publicized investigative series on preventable deaths attributable to nosocomial infection in the Chicago Tribune and the Pittsburgh Tribune-Review , Illinois and Pennsylvania instituted policies requiring hospitals to report data on nosocomial infections to oversight agencies and adopted plans to make comparative data on infection rates available to the public. These states were the first to require systematic, ongoing reporting on nosocomial infection data. The Illinois and Pennsylvania initiatives fall within a clear consumer choice model for addressing nosocomial infections. Rather than compelling hospitals to adopt new infection control practices, the legislation works by publicly disclosing infection rates, which proponents assert will better enable consumers to make appropriate health care decisions as well as provide a market incentive for health care providers to improve infection control in their facilities. Both the Illinois legislation (Hospital Report Card Act) and the new reporting rules promulgated by the Pennsylvania Health Care Cost Containment Council went into effect on January 1, 2004. After the Illinois and Pennsylvania programs were adopted, Missouri and Florida also passed laws instituting nosocomial infection reporting requirements. Finally, a piece of federal legislation titled "The Patient Safety and Quality Improvement Act" was enacted in 2005 (White House, 2005). This legislation created a voluntary, confidential medical errors reporting database and had widespread support from representatives of the health care industry at the time of signing. Whereas consumer advocates support programs that require public disclosure of quality information such as infection rates, the hospital industry regularly opposes such programs, expressing concern that publicizing quality data will lead to increased tort litigation against providers. It is unclear as of the writing of this book what effects these legislative initiatives will have on the quality of health care. Also, another problem with the "consumer choice" approach is that, in most cases, consumers do not have a choice. Their doctor tells them what hospital they are going to, or there is only one hospital that is accessible anyway. Furthermore, most people on their way to a hospital are sick enough that they do not want to stop to evaluate their choices and could not do much with the information anyway. They just want to be admitted and taken care of.

The Executive Branch

In common parlance, the term government in health care refers to the executive branch that delivers health care services, drafts and enforces provider/payer regulations, and administers financing programs, not the legislature that creates the programs or regulatory authority, nor the courts that settle disputes arising under the laws and adjudicates violations of them. Therefore, in the remainder of this chapter the term government refers to the executive branch of government.

Introduction: Government and the Health Care System

In fact, in the United States, government is less involved with the provision of health care (in contrast to the payment for health services, with which it is heavily involved) than in any other industrialized country in the world. The government's role in the U.S. health care system has developed and expanded gradually over a long period of time. In his preface to Stern's (1946) seminal book on governmental medical services in the 1940s, Smillie, one of the first medical sociologists (as was Stern) and a noted public health authority of the day, said: Our forefathers certainly had no concept of responsibility of the Federal Government, nor of the state government, for health protection of the people. This was solely a local governmental responsibility. When Benjamin Franklin wrote "Health is Wealth" in the Farmers' Almanac, he was saying that health was a commodity to be bought, to be sold, to be conserved, or to be wasted. But he considered that health conservation was the responsibility of the individual, not of government. The local community was responsible only for the protection of its citizens against the hazards of community life. Thus government responsibility for health protection consisted of (a) promotion of sanitation and (b) communicable disease control. The Federal Constitution, as well as the Constitutions of most of the states, contains no reference or intimation of a federal or state function in medical care. The care of the sick poor was a local community responsibility from earliest pioneer days. This activity was assumed first by voluntary philanthropy; later, it was transferred, and became an official governmental obligation. (p. xiii) Nevertheless, the government at all levels— federal, state, and local— now plays a major role in the U.S. health care system. Although it is restricted compared with the governments Nevertheless, the government at all levels— federal, state, and local— now plays a major role in the U.S. health care system. Although it is restricted compared with the governments of other nations, in terms of dollars spent and policies developed, its role looms rather large.

Where the Money comes from within the System

In the United States, health care is paid by some combination of the patient, the provider, and a third-party payer. Money paid directly by the patient for health care costs is referred to as "out-of-pocket." Charity care and forgiven debts are the terms providers use when they have borne the cost of providing care. Anyone responsible for payment of a health care cost other than the patient (or the patient's family) or the provider is a "third party payer." Third-party payers include the patient's or his or her relatives' employer(s), private insurance companies engaged by the patient or another party, charity organizations, and federal, state, and local governments. In many cases, several of these parties— patient, provider, and third-party payers— come together to pay a single bill. To use a typical example, a child might visit a pediatrician who would then receive a small "copay" from the mother ("out-of-pocket") during the visit. Then the pediatrician's office would bill a private insurance firm, which would pay some or the remainder of the bill. If the pediatrician is not fully reimbursed by the third-party payer, he or she would absorb the unpaid balance as charity care or forgiven debts. Very complicated relationships can enjoin three or more payers. In the United States, third-party payers (or "payers") are generally categorized as private or public. Within the private sector, private health insurance companies and outof-pocket expenditures are primary. Within the public sector, federal, state, and local governments all provide funding for health care. The public sector may act as a provider of services or as a third-party payer. For example, some health care programs are operated and paid for directly by the government: the federal Department of Veterans Affairs health care system, state mental hospitals, and public general hospitals operated by local governments. These are all supported mainly by tax revenues. On the other hand, the Medicare program acts as a third-party payer in that it does not provide services, but only the money to pay for health services supplied by hospitals, physicians, and others.

Physician Licensure

In the United States, the medical license is granted by the states. To qualify for a medical license in New York State, for example, one must hold an MD or DO (doctor of osteopathic medicine) degree or its equivalent from a school meeting the state education department's requirements; have certain postgraduate (residency) practice experience; pass a medical licensure examination as designated by the department; be a citizen or resident alien; be of "good moral character"; and pay a fee. In our time, few medical school graduates enter practice before completing at least 3 years of residency training.

SQ 1) What are the primary concerns of those who oppose an expanded role of government health care?

In the book it stated that the Government had some role but its services are known as "Police Power" that is used for the health and safety of the people to help the people with medical needs and to ensure that the people are getting what is needed in their medical life. Although there is the "Police Power" the government also made another thing known as the local government to help ensure that the people are receiving the help they need. This came down to a separation of powers so that the government could not get to involved. The primary concern was that the government may get to involved and steal some of the money. Therefore there is a separation of powers. There was a court trial stating that the Government could stay involved with just the 2 powers with the Federal legislative and the executive branches staying in the checks and balances. Another concern was that the government sometimes "blurs" their powers and delegates to ensure that they stay in some sort of power.

SOME POLICY ISSUES IN MC

In the mid-1990s, a longtime observer of the MC scene laid out a list of what he thought would and should happen under MC over the next 10 years (Dennis L. Kodner, personal communication with Jonas, autumn 1996): An increase in the practice of population-based care An increase in the use of physician/nonphysician team care The development of highly sophisticated medical, health, and management informa4. tion systems The return of physician control Increased public sector enrollment: Medicare/Medicaid "Carve-outs" (health services sectors set outside the MC system), for example, mental health, substance abuse, and high-cost subspecialty care Increased insurance company ownership of MCOs and decline in insurance company involvement in indemnity insurance. Decline of both group and staff-model plans with a concomitant rise in other forms, such as the integrated delivery system Competition among MCOs on the basis of quality Going from managed cost to MC A similar list was developed by Barton (1999, p. 31), who also added rationalization of resource use, greater accountability, more disease prevention and health maintenance, and improved quality. The list by Shortell, Gillies, Anderson, Erickson, & Mitchell (1999) is also similar. However, 17 years later, we see that the emphasis on quality and population health has not occurred as completely as predicted. Luft (2003) has described the problem of defining MC and, therefore, of evaluating MCOs on quality, access, and cost: The collection of health plans commonly referred to as "managed care" has come to include an astonishing variety of forms. Although a few are tightly integrated prepaid group practices, a much larger number reflect the complex mixes of associations of clinicians and institutions into provider groups and insurers that face myriad, sometimes conflicting, incentives and employ widely disparate information systems. Managed care plans also differ in the mix of prepaid and fee-for-service patients they enroll and the associated payor sources with which they must interact. Given this heterogeneity, it is difficult to meaningfully compare the quality of managed care plans as a group to fee-for-service plans or to assess the relative performance among types of managed care plans. (p. 1373) Therefore, the controversy that has followed the rise of MC regarding its ability to meet our health care goals continues today and opinion is mostly unfavorable. For example, we still question the effect of MC on the doctor- patient relationship. Does MC harm the relationship between physician and patient? There is evidence brought to bear on both sides of the argument (e.g., Alexander & Lantos, 2006; Light, 2006). Further research may resolve this issue and others related to the desirability of MC. However, the continual change of MCOs in response to critics— both consumers and providers— poses difficulties in obtaining convincing answers. MC has changed dramatically in response to its critics. Thus, for example, RAND (Marquis, Rogowski, & Escara, 2005) put forward two nearly polar opposite explanations for the failure of HMO enrollment to drop in the late 1990s and early 2000s following much reported consumer disfavor with MC: (a) Many consumers were more satisfied with their HMOs than had been thought; and (b) many HMOs relaxed their cost containment restrictions in order to avoid losing market share.

FUTURE OF THE OBAMA HEALTH PLAN

Increase in public-sector involvement in the health care system under the ACA has been strongly challenged. The rhetoric of Americans who wish to limit government has been perhaps more explicit and strident than at any time in memory, and antigovernment sentiment appears more widespread and powerful. The rise of the Tea Party as the most influential representative of conservative America has been a hallmark of this period. The mission and core principles of the Tea Party movement, in its own words, are: The Tea Party Patriots' mission is to restore America's founding principles of Fiscal Responsibility, Constitutionally Limited Government, and Free Markets. (Tea Party Patriots, 2012) Thus, it is not surprising that, since the ACA was passed, the Republicans in Congress have repeatedly attempted to repeal the legislation. They explain themselves on the Republican website GOP.gov by saying that: "Because the new health care law kills jobs, raises taxes, and increases the cost of health care, we will immediately take action to repeal this law" (GOP.gov, 2012). As the eighth edition of this book was being written, Republicans were still attempting to repeal the legislation, and Congress found bipartisan support to delay important provisions of the ACA, including the tax on generous health plans and a separate tax on health insurance providers. The excise tax on manufacturers of medical devices, which took effect in 2013, was suspended through 2017. The White House and many economists have defended the "Cadillac tax" on high-cost employer-sponsored health plans as a way to reduce health costs and make the health care system more efficient (Herszenhorn & Pear, 2015). The Commonwealth Fund explains: A last-minute deal in Congress delayed or suspended some of the taxes included in the ACA— one on medical devices, one on health insurers, and one on high-cost health plans. Estimated cost: $35.8 billion in lost revenue. To be clear, most of the ACA's funding comes from general revenue, and so isn't directly impacted by these taxes. (Blumenthal & Squires, 2015) In addition, many states have still rejected the Medicaid expansion, which is a feature of the ACA whereby the income eligibility criteria are expanded to include more people and the costs of adding health care for a greater number of people is paid by the federal government at first. This is a blow for the goal of attaining full health care coverage. Another disappointment concerning the ACA has been the performance of the Consumer Operated and Oriented Plan Program (CO-OP). "The Affordable Care Act calls for the establishment of the Consumer Operated and Oriented Plan (CO-OP) Program, which will foster the creation of qualified nonprofit health insurance issuers to offer competitive health plans in the individual and small group markets" (Centers for Medicare & Medicaid Services [CMS], 2015). However, the Commonwealth Fund assessment is that this will not be a major defeat: Underfunding for risk corridor programs designed to stabilize premiums, unmanageable deadlines, restrictions on marketing, the difficulty of setting up brand new insurance companies— there are many culprits behind the collapse of 12 of the 23 ACA-funded CO-OPs (Consumer Operated and Oriented Plans). But evidence that the folding CO-OPs are a harbinger of a broader collapse of the ACA exchanges remains scant. Rather, the CO-OPs' struggles have highlighted the substantial barriers to injecting competition into insurance markets— and how both economics and politics can get in the way. (Blumenthal & Squires, 2015). The future of the ACA is still in doubt as Republicans have promised to overturn it if a Republican president is elected in 2016. However, even if the ACA is overturned, many of its policies will remain, as they represent trends that were underway before passage of the bill and have much support in all sectors of the health care system.

EQUITY AND ACCESS TO HEALTH CARE

Is access to health care equitable in the United States? Here, the evidence is quite clear. People without health insurance (or with poor health insurance) have much reduced access to health care. As we have discussed, the United States finances health care through a mixed system, based largely on employer-based health insurance and the public insurance programs for the elderly and disabled (Medicare) and the poor (Medicaid). This patchwork system leaves 41 million people without health insurance (Kaiser Family Foundation, 2015). Millions more are underinsured, that is, they do not have comprehensive coverage. This can mean high deductibles and copays and limited coverage for a variety of health care services, including mental health services, medical equipment, and preventive care (Lee & Tollen, 2002). The health care access problems of the uninsured are well documented. The uninsured are much less likely to have a "usual place to go" for medical care. If they have a usual place for health care, they are less likely than insured persons to have a physician's office as their site of care. Uninsured adults are more likely to use "safety net" providers, such as community health centers, emergency rooms, and public health or free clinics as their usual place for health care. They are less likely than the insured person to see the same health care provider each time they obtain health care. They are more likely to report that they do not get needed health care, and they have fewer ambulatory care visits. Research has shown that uninsured persons are significantly more likely to delay seeking health care. Lack of health insurance has been found to be significantly related to the failure to fill a recommended prescription, and it is found that medications, even when filled, are not taken as directed, but saved or spread out over a longer than prescribed period of time to save money (Kaiser Family Foundation, 2002). Not all Americans have the same probability of being uninsured. National surveys have consistently found that age, SES, race, and ethnicity are predictors of being uninsured or underinsured. The majority of the uninsured and underinsured are employed. Until the Affordable Care Act, typically, 18to 34-year-olds were the least likely to have health insurance, either because they could not afford it or because they chose not to be insured, preferring to spend that money on something else. People who have had only a high school education or less schooling are more likely to be uninsured. A higher percentage of Hispanics and African Americans are uninsured compared to non-Hispanic Whites. Foreign-born noncitizens rank the highest of all in rate of being uninsured (Jonas & Kovner, 2005; Kaiser Family Foundation, 2006, 2015). Another factor leading to inequities in access to health care is geographic location. People who live in rural America and those who live in inner cities have reduced access to health care, even if they have health insurance. These areas often lack health care resources, including physicians and other health care providers and facilities, particularly easy-to-reach, comprehensive hospitals. Rural residents generally face a greater financial burden for obtaining care than do urban and suburban residents, and mental health services can be scarce (Reschovsky & Staiti, 2005). Rural areas tend to attract fewer doctors than urban areas. Even though 20% of Americans live in rural areas, only 9% of U.S. physicians practice in rural areas (AHRQ, 2005). The problem of equity, in both access to and quality of health care, is well known, and there have been efforts to remedy the problem starting early in the 20th century when reformers began to focus on securing universal health care coverage in the United States. The history of the efforts to correct the inequities in the U.S. health care system is described at length in Chapter 8—"History of Change From 1990 to the Present: Piecemeal Reform."

EQUITY AND THE QUALITY OF HEALTH CARE

Is the distribution of quality health care equitable in the United States? An examination of disparities in quality of care suggests that it is not (Fiscella, Franks, Gold, & Clancy, 2000). For example, lower SES is associated with receiving fewer Papanicolaou tests, mammograms, childhood and adult influenza immunizations, and diabetic eye exams. Lower SES is also associated with late enrollment in prenatal care and lower quality ambulatory and hospital care. Racial and ethnic status is linked to quality of care received. Elderly African Americans receive fewer preventive medicine procedures when compared with elderly Whites. African Americans, in general, receive less intensive hospital care, and Hispanic women receive fewer medical procedures and preventive measures as compared to Whites. African Americans have also been found to have higher rates of end-stage diabetic conditions, such as amputations, indicating poor-quality ambulatory care. However, a recent study by the RAND Corporation (Asch et al., 2006) suggests that inequities in health care quality may not be as important as deficiencies in the overall level of quality in the United States. In the RAND study, health care quality differed little between people in different socioeconomic, racial, ethnic, and geographic groups. Rather, the researchers found that health care was mediocre for all groups, equally. The study suggests that disparities in quality of care may be closing, but the overall quality of health care for all Americans needs much improvement. The discrepancy between the RAND study findings and those of previous research had not been resolved at the time this book was written, but it is an important issue that should generate a great deal of research in the future.

THE HEALTH CARE FUNCTIONS OF GOVERNMENT: The Constitutional Basis of Governmental Authority in Health Care.

It is argued that a very significant role for government in health care delivery is justified by the amount of money government spends on it. This says nothing about the calls for major reforms that could be undertaken by no agency other than government that echo down to us from the early 1930s and resonate in many voices today. But such a role has a constitutional basis as well. To understand government operations in the health care delivery system, it is to understand the structure of the government itself. 1 A basic principle of the U.S. Constitution is that sovereign power is to be shared between the federal and state governments, a principle called federalism . At its heart, the U.S. Constitution is an agreement among the original 13 states to delegate some of their inherent powers to a federal government, on behalf, not of themselves as separately sovereign entities, but of, as the Preamble to the Constitution says, "the people of the United States." As part of this agreement, in the Tenth Amendment to the Constitution, the states explicitly reserved to themselves the rest of the power: "The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people." Because it is not explicitly mentioned in the Constitution, among the powers reserved to the states is the "police power." It is the latter that forms the basis of the states' role in health (Mustard, 1945, pp. 17- 21). As Grad (2005) points out: In the states, government authority to regulate for the protection of public health and to provide health services is based on the "police power"—that is, the power to provide for the health, safety, and welfare of the people. It is not necessary that this power be expressly stated, because it is a plenary power that every sovereign government has, simply by virtue of being a sovereign government. For purposes of the police power, the state governments— which antedate the federal government— are sovereign governments. . . . [T]he exercise of the police power is really what government is about. It defines the very purpose of government. (p. 11) Among the states' other inherent powers are those of delegation of their own authority. The states used this power to create a third tier of government, local government. Most states have delegated some of their own health powers to that tier. The constitutional basis of the federal government's health authority is found in the powers to tax and spend to provide for the general welfare, and regulate interstate and foreign commerce (see the Preamble and Article 1, Section 8 of the Constitution; Grad, 2005, pp. 11- 15). The other basic constitutional principle affecting health and health services is separation of powers . The Constitution divides the sovereign power of the federal government among three branches of government: executive, legislative, and judicial. Under separation of powers, each branch of the federal government has its own authority and responsibility, spelled out in the Constitution. Furthermore, the Constitution spells out curbs on the powers of each branch, exercised by the other two. This arrangement is called the system of checks and balances . One very important check on the power of both the federal legislative and executive branches, judicial review of the constitutionality of their actions, is not found in the Constitution, however. It was established early in the 19th century by the third Chief Justice of the Supreme Court, John Marshall, and his colleagues on the bench. It has become an accepted part of the U.S. constitutional system only because the other two branches have granted the Court that authority in practice and have followed its determinations. In organizing themselves, the state governments have followed fairly closely the tripartite form of government established under the U.S. Constitution, with checks and balances and separation of powers. At the tertiary level of government, the boundaries between the branches at times become blurred, however. For example, in some suburban and rural areas, the local chief executive officer presides over the local legislative body. Nevertheless, in most U.S. jurisdictions, separation of powers is a major principle of government.

SQ 2) What are the key government programs the finance health care in the United States and what persons do they cover?

Key government programs are Medicare, Medicaid, and CHIP. Medicare was first founded in the 1960's and was a service for those who were 65 and older to help pay for medical expenditures. Medicaid covers the people who are not available for Medicare and CHIP. There is a variety of levels in Medicaid, Medicaid is a federal based program. There is different requirements for applicants to go through to see if they are eligible for this program. Chip pays for children who are not available for Medicaid. Payments are based on the expenditure and the plans that are approved. There is many kids in this program.

Licensing

Licensing is a basic government function in health care. The licensing process for individual practitioners first establishes minimum standards for qualification. It then applies those standards to applicants to determine who may and who may not deliver what kinds of health services. Licensing of health care institutions sets minimum standards for each facility and their personnel as a group, applies the standards, and determines whether the institution may operate. The licensing authority is one of the most significant of the health powers residing with the states. The manner in which it is used is a major determinant of the character of the health care delivery system. The medical licensing system is particularly significant in that regard. Because no one can practice medicine without a license, the system has given physicians tight control over the central product of the health care delivery system, medical services. By exercising this control, physicians have largely determined the structure of the health care delivery system: how it is organized, the types and functions of the institutions, and the powers of the several categories of personnel who work in it.

Barriers to accessing care

Limited insurance coverage has already been addressed as a barrier to accessing care. In addition, the stigma of mental illness prevents many people from seeking help; what are some others? Did you think of lack of transportation for care, lack of providers of care, denial of disease by patient and/or family, limited functional ability of patient?

Depression module

Major depressive disorder is the leading cause of disability in the U.S. for ages 15-44. Major depressive disorder affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year. While major depressive disorder can develop at any age, the median age at onset is 32. Major depressive disorder is more prevalent in women than in men.

The Federal Government and the Provision of Health Services.

Many federal agencies are involved in the delivery of personal and community health serti0055 vices. The U.S. Department of Health and Human Services (DHHS) is the most important federal actor in health and health care. There are two other federal agencies with major health services responsibilities: the Department of VAs and Department of Defense (DOD). Other federal agencies with significant health-related responsibilities include the Department of Agriculture (nutrition policy, meat and poultry inspection, food stamps), the Environmental Protection Agency (EPA), and the Department of Labor (administering the Occupational Safety and Health Act).

Other Federal Departments

Many other federal departments have some health services responsibilities, as previously noted. Several are discussed here. The Department of VAs provides many services to veterans (U.S. Department of Veterans Affairs, 2015a). After military service, the U.S. veteran becomes entitled to a remarkably broad range of health services through a health care subsystem, the precise equivalent of which is not found in any other nation in the world. This fact is doubtless related on the one hand to the lack of a national health insurance program for the general population and on the other to the political power of the veterans' organizations. A veteran is defined as anyone who served 90 days or more in an armed service, but a veteran must have received an honorable or general discharge in order to be automatically eligible. The specific rules covering health care eligibility for the many classes of veterans are complex. They may be reviewed in detail on the VA website. A financial means test for certain classes was introduced by the Bush administration in 2003. The number of patients with service-connected disabilities treated in VA hospitals has been dropping over time, although with the advent of the Iraq war it is now again on the increase. The VA is the second largest federal department, with a workforce of over 327,000 employees. The VA operates the largest integrated health care delivery system in the United States and provides a wide range of primary and specialized medical care, as well as social services. Services and benefits are provided through a nationwide network of 151 medical centers, 300 veteran centers, 820 community-based outpatient clinics, 135 community living centers, 6 independent outpatient clinics, 103 residential rehabilitation centers, 139 integrated disability evaluation system sites, 131 cemeteries, and 56 regional offices. p0285 There is a major shift under way from a primary focus on inpatient care to one on outpatient services, health promotion and disease prevention, and easier access to the system. In this regard, the VA is the largest integrated provider of health care education. The VA also trains physician residents and other health care trainees. The VA supports medical research in areas that most impact veterans and their dependents and other beneficiaries (U.S. Department of Veterans Affairs, 2015a). The VA medical care system serves an enormous number of people: p0290 p0295 There are 8.9 million people enrolled in the VA health care system, up from 7.7 million in 2005, and 8.3 million in 2010. In 2013, there were 86.4 million outpatient visits, up from 57.5 million in 2005, and 80.2 in 2010; 694,700 inpatient admissions up from 586,000 in 2005, and 682,300 in 2010. (U.S. Department of Veterans Affairs, 2015b) p0300 The DOD oversees the health services of the various branches of the military through the Military Health System. Each of the armed forces— the Army, Navy, Air Force, and Marines— has its own network of health facilities: hospitals, clinics, and field posts (Assistant Secretary of Defense for Health Affairs, 1990, 1996, and the website). All DOD health personnel are members of the military and salaried according to their military ranks (without relation to the specific services they render). The same basic structure prevails in times of war or peace. Health promotion and disease prevention are emphasized and integrated with the delivery of treatment services. Through both its own facilities and contracting arrangements with civilian providers, DOD provides health services to members of the armed forces, their dependents, surviving dependents of service people killed while on active duty, and military retirees and their dependents. Servicemen and women are eligible for retirement benefits after a minimum of 20 years of service. The health services part of that package is paid in addition to the VA benefits for which they may be eligible. An unusual aspect of military medical departments is that they are charged not only with providing a full range of direct health services but also with providing for the environmental health and protection of their military communities. This unification of administrative responsibility for personal and community preventive and treatment services is rarely found elsewhere in the U.S. health care delivery system. The U.S. Department of Agriculture (USDA) oversees the Food Safety Inspection Service (FSIS); the Food and Nutrition Service (FNS), which includes the Women, Infants, and Children (WIC) nutritional program, school breakfast and lunch programs, and the Food Stamp program, which helps poor people to buy food; the Center for Nutrition Policy and Promotion (CNPP), which, in cooperation with the DHHS, periodically issues dietary guidelines for the nation; the Animal and Plant Health Inspection Service (APHIS); and the Rural Utilities Service (RUS), which includes telemedicine programs. The USDA conducts research on the nutrient composition of foods, food consumption, and nutritional requirements. The FSIS and APHIS are operated in cooperation with the FDA (USDA, 2006). Focusing on preventive activities in the workplace, the Occupational Safety and Health Administration (OSHA) is part of the Department of Labor. OSHA uses criteria developed by the National Institute for Occupational Safety and Health (NIOSH), part of the CDC, to set national standards for occupational safety and health (Brock & Tyson, 1985). Since 1970, workplace fatalities have been reduced by more than 65% and occupational injury and illness rates have declined by 67%. At the same time, U.S. employment has almost doubled. Worker deaths in America are down— from about 38 worker deaths a day in 1970 to 12 a day in 2013. Worker injuries and illnesses are also down— from 10.9 incidents per 100 workers in 1972 to fewer than 3.3 per 100 in 2013 (OSHA, 2015). The major responsibilities of OSHA are to develop workplace health and safety standards, to enforce and gain compliance with the standards, to engage in education and training, to help the states in occupational safety and health matters (26 states have their own occupational safety and health programs), and to aid business in meeting OSHA requirements (OSHA, 2015). There are a few industries that are not covered by OSHA. For example, the health and safety of miners is the province of the Bureau of Mines in the Department of the Interior. The EPA is an independent unit of the federal government created during the Nixon administration that was elevated to cabinet-level status during the Clinton administration (EPA, 2006). It has major responsibilities for the control of air and water quality and pollution, solid waste disposal, pesticide contamination, radiation hazards, and toxic substances (EPA, 1988, 1989, and the website). The EPA conducts research on air, water, and land pollution control technology and the effects of pollution on humans, develops criteria and issues national standards for pollutants, and enforces compliance with these standards.

Where the Money Goes

NHE are calculated by the CMS, Office of the Actuary, National Health Statistics Group. NHE comprise the following two major categories: (a) Health Consumption and (b) Investments, a category made up of Research and Structures and Equipment. Most expenditures fall within Health Consumption, and most of these are for personal health care (hospital care; physician and other professional services, including dentistry; nursing home and home health care; and medical products, including prescription drugs and durable medical equipment). Complementary and alternative medicine (CAM) is included under Other Professional and personal health care Services, and vitamins and minerals supplements are included under other medical products. The other two categories within Health Consumption are: (a) Government Administration and Net Cost of Health Insurance; and (b) Government Public Health Activities. NHE does not include expenditures for a much broader definition of health care that might include (nonmedically supervised) dieting and weight loss, health and fitness clubs, sporting goods and related recreation, and healthy foods. How does the United States spend its health care dollars? Figure 5.1 provides an overview. In short, hospital care is the largest single category at 32% of total, followed by physician and clinic care at 20%, and prescription drugs at 9%. Then about 22% went for all other clinical and professional care, nonacute facility care such as skilled nursing facilities, and durable and nondurable equipment. Administration (including both government and private insurance) is relatively high at 7% compared to the OECD country average of 3%, though not much higher than other multipayer insurance health systems such as France and Germany (OECD, 2011, 2015). How are NHE allocated by health condition and characteristics of patients? Through its Medical Expenditure Panel Survey (MEPS) program, the Agency for Healthcare Research and Quality (AHRQ) maintains the most complete source of data on the cost and use of health care and health insurance coverage. 4 Through large-scale surveys of families and individuals, their medical providers (doctors, hospitals, pharmacies, etc.), and employers across the United States, MEPS collects data on the specific health services that Americans use, how frequently they use them, the cost of these services, and how they are paid for, as well as data on the cost, scope, and breadth of health insurance held by and available to U.S. workers (AHRQ, 2012). According to the Centers for Disease Control (CDC), "Chronic diseases are responsible for 7 of 10 deaths each year, and treating people with chronic diseases accounts for 86% of our nation's health care costs" (CDC, 2016, p. 1). Although Figure 5.2 shows that trauma-related disorders are the single most expensive category of spending in 2013, it should come as no surprise that the vast majority of the top 20 conditions by total expense measured in the MEPS survey are for chronic conditions. Note that although current NCHS definitions consider a condition chronic if it persists for more than 3 months, conditions related to pregnancy are never considered chronic (NCHS, 2011, pp. 486- 487). Chronic conditions are also considered some of the most preventable of all health conditions (CDC, 2016). Figures 5.3 and 5.4 show the high concentration of health care spending in the population and its persistence from year to year. In 2013, half the population accounted for only 3% of total health care spending. Five percent of people accounted for 49% of spending, and 1% accounted for 22% of expenditures. However, only 14% of the population in the top 1% of health care spending in 2012 were also in the top 1% in 2013. Although 74% who were in the top 50% in 2012 were also in the top 50% in 2013, 73% who were in the lowest 50% in 2012 were also in the lowest 50% in 2013. The implication is that there is both a strong chronic and episodic utilization of health care. Significant use of health care (the top 50% of population accounting for 97% of spending) within a calendar year is a strong predictor of significant use in the next. However, the most extreme users of health care in one year are unlikely to be extreme users in the following year. Another way to look at it is that about 120 million people who are in the top 50% will be in the top 50% the following year. On the other hand, about 80 million people probably alternate between the top 50% and bottom 50% of health care users each year. About 3 million people will have extreme use of health care for 1 year only. About half a million people will have extreme use of health care for several years in a row. Although numerous studies advise of the relatively significant resources spent during the last year of life— and even more during the last 6 months— Emanuel and Emanuel (1994) argue: They also assert that these savings "would not restrain the rate of growth in health care spending over time. Instead, this amount represents a fraction of the increase due to inflation in health care costs and less than (the amount) needed to cover the uninsured population" (p. 543). Accepting this, we cannot assume that less aggressive care at the end of life will solve the financial problems of the health care system.

Mental Illness Historical Perspective Module

Mental illness has always carried with it a negative stigma in our country, probably because people are afraid of it. In past years most people with mental illness were hidden away from the public in various places. Then the Quakers became involved to try to provide kinder custodial care - this era was known as the "Moral Era". Later we had the "Biological Era" where the emphasis was to treat mental illness like a physical disease by trying to stop the symptom. They used various methods of "shocking the nervous system" to stop the symptoms i.e. deep sleep therapy, insulin shock therapy and electroshock therapy. The 1950's "Institutional Era", was the time when our state mental hospitals were packed with patients. The only real treatment during this time was administering psychoactive medications to the patients-like Thorazine. These medications controlled the behavior and kept people from reacting to the overcrowded conditions. In 1955 a governmental committee-Joint Commission on Mental Illness and Health- was established and began to address quality of care and access to care. The federal government continued its involvement in the 60's and 70's. One result of this was that the federal government decided that individuals should be sent back to their communities for treatment rather than be housed in state mental hospitals (deinstitutionalization) - make sure you go to the article link at the top of the page under Module Requirements and review this concept. Thus, from the 70's until the present the majority of mental health services have been provided in communities through community mental health centers and other programs. The focus of all these programs is with severe mental illness.

Focus Points psych Module

Mental illness is associated with increased occurrence of chronic diseases such as cardiovascular disease, diabetes, obesity, asthma, epilepsy and cancer. Mental illness is associated with lower use of medical care, reduced adherence to treatment therapies for chronic diseases and higher risks of adverse health outcomes. Many people suffer from more than one mental disorder at a given time. Nearly half (45 percent) of those with any mental disorder meet criteria for two or more disorders, with severity strongly related to co-morbidity. Mental disorders were one of the five most costly conditions in the United States in 2006, with expenditures at $57.5 billion. Over 8.9 million persons have co-occurring disorders — that is, they have both a mental and substance use disorder.

Stigmatization

Most adults with mental health symptoms (78 percent) and without mental health symptoms (89 percent) agreed that treatment can help persons with mental illness lead normal lives. 57 percent of all adults believed that people are caring and sympathetic to persons with mental illness. Only 25 percent of adults with mental health symptoms believed that people are caring and sympathetic to persons with mental illness. Mental health stigmatization due to embarrassment and social avoidance can lead an individual reluctant to seek help/treatment. Problems with mental health are very common in the United States, with an estimated 50% of all Americans diagnosed with a mental illness or disorder at some point in their lifetime. Mental illnesses, such as depression, are the third most common cause of hospitalization in the United States for those aged 18-44 years old, and adults living with serious mental illness die on average 25 years earlier than others. The reports and other products in this section can serve as resources to students, public health officials and other health professionals who need up-to-date statistics and data sources around mental health and mental illness. However, these lists of reports and data tools are not exhaustive. The National Health Interview Survey (NHIS) has monitored the health of the nation since 1957. NHIS data on a broad range of health topics are collected through personal household interviews. For over 50 years, the U.S. Census Bureau has been the data collection agent for the National Health Interview Survey. Survey results have been instrumental in providing data to track health status (including mental health), health care access, and progress toward achieving national health objectives. The CDC: "The economic burden of mental illness in the United States is substantial—about $300 billion in 2002. Mental illness is also associated with chronic medical diseases such as cardiovascular disease, diabetes, and obesity. Mental illness surveillance is a critically important part of disease prevention and control."View to the file below and read more about some common mental illness statistics:

FOR-PROFIT VERSUS NOT-FOR-PROFIT

Much of the controversy surrounding health care delivery reorganizations, such as introduction of MC, and the creation of large, integrated health systems concerns profit-making and its compatibility with the provision of quality, efficient, and accessible health care. For example, a prediction of the effects of MC as it has evolved made by health policy analyst Victor Fuchs (2002) was rather grim: The announcement that most of the nation's biggest insurers— Aetna, CIGNA, Humana, the United Health Group, and WellPoint Health Network— will be introducing a new kind of health plan during the next year or two signals the beginning of a new era in health insurance in the United States. These plans feature a complicated menu of premiums, co-payments, and deductibles that will add impetus to the trend of employers offering a defined [monetary] contribution for health benefits. . . . One of their major effects will be to shift the burden of health care costs from employees who use little care to those who use more. Thus, the new plans will be another nail in the coffin of health insurance as a form of social insurance. (p. 1822) As Randel, Pearson, Sabin, Hyams, and Emanual (2001) put it, in terms that still apply: The growth of managed care in the United States has been paralleled by a rising tide of anti- managed care sentiment. The "managed care problem" is understood generally as the need to protect individuals against large companies that care more about their bottom line than about people. (p. 44) As noted in the quote from Koop (1996; certainly no radical reformer) at the beginning of this chapter, it is the question of for-profit versus not-for-profit health care, not just MC. It is the question of whether having the health care delivery system become a major profit center for corporate America (the insurance industry) is healthy (in a variety of senses) for America and Americans. It is the issue at the center of virtually every other health care issue related not only to MC but to the future of the health care delivery system as a whole. The question is not a moral one. It is a functional one. Can a profit-making system and the so-called free market solve the myriad problems of the U.S. health care delivery system, as spelled out earlier in this chapter and elsewhere in this book? Because the focus of a for-profit system must be on profits, by definition, and because the solution of so many of the problems not only cannot generate profits but also would cost considerable sums of money, the answer would appear to be no. Therefore, we turn to a consideration of health care reform.

Nurses in Expanding Roles

Nurses in advanced practice, the nurse practitioners or advanced practice nurses, can provide primary ambulatory care, normal pregnancy care and delivery, and routine anesthesia at least as well as physicians. In each instance, the initial informal efforts to create a new arena for nursing were followed by the establishment of standards, formal curricula in approved programs, and, more recently, the preparation for advanced levels through master's and doctoral degree programs in universities. The development of each new form of and forum for nursing was also accompanied by a serious struggle for acceptance, especially within the medical profession. This was especially true if the new form was or could be taken to be in economic competition with physicians. (APRNs)—RNs with specialized training and advanced degrees— has risen from about 30,000 in 1990 to about 140,000 in 2010. In addition, APRNs are considered to be less rushed and more holistic in their approach to patients, factors increasing patient satisfaction. Some states allow APRNs to practice more independently and comprehensively than others. In these terms, in 2002 the following states were considered the best environments to practice as an APRN: New Mexico, Arizona, Iowa, Oregon, Montana, Maine, and Washington. The least favorable, most restrictive, states were Alabama, Virginia, Georgia, and South Carolina.

From Nursing Shortage to Nursing Oversupply, and Back Again

Nursing shortage started from poor working conditions, poor pay, poor professional image (Probably from tv lets be honest), and problems with the doctor nurse relationship, and better opportunities. They started creative solutions called 12 hour shift. They also closed hospitals and merged them to solve some problems since many nurses started to retire or leave. The University of California's Pew Center for the Health Professions (CHP; 1999) predicted that 200,000 to 300,000 hospital nurse positions could be eliminated by the year 2000. Suddenly, a vast surplus appeared to be on the horizon. They then again has a problem hiring nurses in 2001. Also due to the baby boomers needing help but many nurses did not want to work or many new nurses did not want to apply to school due to job dissatisfaction and retention. IN 1999 CALIFONRIA ELIMINATED NURSE TO PATIENT RATIO!!!! THIS IS NOT GOOD!!!

Out-of-Pocket Expenditures

Out-of-pocket expenditures include direct payments to providers for noninsured services, extra payments to providers of insurance-covered or managed care-covered services that bill at an amount higher than the insurance/managed care company pays for that service, and deductibles and coinsurance on health insurance/managed care benefits. A deductible is a flat amount; for example, $200 per individual or $500 per family, that a health care beneficiary must pay out-of-pocket before the insurance company will begin paying for any health services received during some time period (usually a calendar year). Coinsurance is a share of the cost— for example, 20% of the payment for each service covered by insurance— for which the beneficiary is responsible. Under managed care, beneficiaries receiving health services from a provider of their choice within the plan (a so-called "point-of-service" arrangement) or out-of-plan entirely will usually pay for some or all of the excess charges out-of-pocket. Today, however, there are an increasing number of "luxury" managed care organization (MCO) plans, available at an extra cost above that normally borne by the beneficiary's employer. They provide for unfettered patient choice of physician, without prior authorization and without additional payment beyond the usual deductible or coinsurance. Out-of-pocket expenditures accounted for about 12% of national health care consumption in 2013. This is down from over 16% in 2000, nearly 25% in 1980, and over 50% in 1960.

Private Medical Practice

Overall, 67.9% of visits were made to physicians who were owners of the practice. More visits, 80.4%, were to practices that were either owned by a physician or a group of physicians than other ownership arrangements. Over one-half of office visits (56.6) were made to physicians who were part of a group practice, defined as having three or more physicians (NCHS, 2015b, Table 2). The percentage of U.S. physicians who own their practices has declined over the past two decades. The percentage of physicians practicing in independent, solo, or smallgroup practices declined, whereas the percentage of physicians practicing in larger practices increased. The percentage of physicians practicing in independent or solo practices declined from 37.2% in 2000 (NCHS, 2002 Table 2) to 31.5% in 2010 (NCHS, 2015b, Table 2), whereas the percentage of physicians practicing in larger practices (two or more) increased from 61.5% in 2000 to 68.1% in 2010. About one fifth, or 22.6 % of visits occured in multispecialty practices, and 45.8% were to single-specialty practices in 2010. The remaining 31.5% of office visits were to solo practitioners The trend toward group practice and away from physician ownership is especially true for younger physicians. Among the reasons for this mode of employment that younger physicians find attractive are receiving a regular income and comprehensive fringe benefits; the provision of medical malpractice insurance by the employer; regular hours and regular night and weekend coverage schedules; avoiding the difficulties associated with entering into private practice in many desirable living areas, many of which have an over-abundance of physicians; avoiding the high costs of starting a private practice, a particular burden to so many of today's new physicians who start professional life with a large debt accumulated during their medical training; and finally, avoiding the tribulations of office practice dealing with managed care company scrutiny.

Resource allocation and provision of mental health services

Payers of mental health services include private insurances, Medicaid, Medicare, V.A. Administration and some state/local programs. The problem here is while these insurances will pay, they will generally only pay for crisis management and stabilization of the client, therefore access to care for most clients is limited. Why do you think third party payers limit payment for services of mental health? (Length of treatment, difficulty in projecting outcomes). Is this OK? Moral? Ethical? Good business sense? Though your text doesn't address this, it is something important for you to think about. The following link will take you to a great reference for mental health services.

OFFICE OF THE NATIONAL CORRDINATOR FOR HEALTH INFORMATION TECHNOLOGY

Perhaps the most influential health information initiative is that of the Office of the National Coordinator for Health Information Technology (ONC) located in the U.S. Department of Health and Human Services. The ONC has four sequential goals: informing clinicians, interconnecting clinicians, personalizing health care, and improving population health (U.S. Department of Health and Human Services, 2006). The ONC initiative in health information includes a great deal of private-sector reliance on developing communication standards, software, hardware, and training for those who will use the system.

Primary Care Functions

Primary care and ambulatory care go together like apple pie and ice cream. This is so even though not all primary care is delivered in an ambulatory setting, nor is all ambulatory care primary care. Nevertheless, because they are in most instances closely associated, they will be covered in the same chapter. The primary feature of comprehensive primary care is its integrating role in medical practice. In the past, when nearly all medical services were rendered by a family's general p ractitioner, coordination was almost automatic. Today, a primary care doctor or team can still provide most of the care that is necessary most of the time. But in the context of modern medical knowledge and technology, organization and planning for such a practice must be undertaken. They are GATEKEEPERS.

Primary Care and its Providers

Primary care is the means by which the two goals of a health services system— optimization of health and equity in distributing resources— are balanced. It is the basic level of care provided equally to everyone. It addresses the most common problems in the community by providing preventive, curative, and rehabilitative services to maximize health and well-being. It integrates care when more than one health problem exists, and deals with the context in which illness exists and influences people's responses to their health problems. It is care that organizes and rationalizes the deployment of all resources, basic as well as specialized, directed at promoting, maintaining, and improving health. [Primary care is] the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Health Care as a Determinant of Health

Primary, tertiary, and secondary care. PRIMARY is PREVENTING. Health care is concerning with Secondary and Tertiary. Secondary prevention is concerned with reducing the burden of existing disease after it has developed; early detection is emphasized. Secondary prevention activities are intended to identify the existence of disease early so treatments that might not be as effective when applied later can be of benefit. Tertiary prevention focuses on the optimum treatment of clinically apparent, clearly identified disease so as to reduce the incidence of later complications to the greatest possible degree. In cases where disease has been associated with adverse effects, tertiary prevention involves rehabilitation and limitation of disability. The health care system is less spent on primary care.

Types of Health Service Provided

Primary: Common forms of personal preventive measures are the promotion of personal lifestyle/behavior change (e.g., becoming a regular exerciser), immunization, prenatal care, and periodic health examination for early disease detection. Most of the major causes of acute and chronic morbidity (sickness) are treated in the primary care setting. As of 1996 (the most recent year for which the following data were available at the time of writing), the major causes of acute and chronic morbidity were respiratory conditions, influenza, the "common cold," injuries, other infective and parasitic diseases, hearing impairment, chronic sinusitis, arthritis, hypertension, heart conditions, orthopedic impairments (including low-back pain), and asthma and hay fever. Secondary and Tertiary: Secondary care (the most difficult level to define) includes services that are available in both community hospitals and physicians' offices. Ideally, secondary care is arranged through referral or consultation after a preliminary evaluation by a primary care practitioner. Secondary services include most surgical procedures and the common diagnostic and treatment interventions of such specialists as radiologists, cardiologists, and ophthalmologists. Tertiary care consists of highly specialized diagnostic, therapeutic, and rehabilitative services, requiring staff and equipment "that transcend the capabilities of the average community hospital" (Rogatz, 1970, p. 47). Such care, available largely at major medical centers, includes organ transplantation, open-heart surgery, and other technically complex procedures, complex chemotherapy and radiotherapy for cancer, and the preservation of very-low-birth-weight premature infants. In the United States, both secondary and tertiary health services are highly developed. That development has not always occurred either in response to a well-documented need or in a planned way so as to make for the most efficient use of scarce resources.

Health Care System Performance

Quality, Equality, Proficiency

Cost/Cost-Plus

Reimbursement is how hospitals describe payment received for services they have already provided. Under a cost payment method, the organization providing the service tracks all costs associated with each customer and then asks to be paid that amount. This is similar to how an employee might be reimbursed for expenses incurred during a business trip. The employee would offer receipts for plane fare, hotel, food, and other allowable items and then expect to receive exactly that amount in return. An indemnity plan is one under which the covered party is reimbursed for all expenses he or she incurs. An organization is often paid on a cost-plus basis (so-called because a contract specifies that the organization will be reimbursed for actual costs plus an additional percentage of those costs). The cost-plus method provides an additional margin out of which the providing organization can generate profit after any non project expenses are paid. In practice, no independent entity can be paid in a cost-only manner. Of course, a profit-generating organization will never survive under a pure cost-only reimbursement model, but even nonprofits need more than cost reimbursement to survive. Under any contract there are non reimbursable expenses, and every significant organization has expenses that are not specific to one project. The margin allowed on the cost-plus project is what an organization draws from to pay these expenses. Some people like cost-plus contracts because they provide high levels of transparency and seem to limit profits. However, there are drawbacks. These bills are often so detailed that the payer can understand only the bottom line. 5 In practice, what is reimbursable, as well as ceilings and thresholds on the amounts, must be set. Accounting for utilization of shares of resources can be complicated, and approaches must be agreed on. In addition, cost-plus contracting does not reward the organization, in this case the health care provider, for either better quality or finding new ways to provide services more cheaply. In a true cost-plus system, the contract penalizes the providing organization for cutting costs.

Primary Care and the Health Care System

Some observers believe that the level and quality of primary care provision serve as good markers for the quality of a nation's health care delivery system as a whole. Countries with better primary care tend to be countries that strive toward equity in distribution of health services and toward more equitable income distributions. Second, it is not the number of primary care physicians, or even the ratio of primary care physicians to specialists, that accounts for the differential effects of the health services across those countries. Rather, the differences are a result of how the resources are distributed, whether or not they are organized to achieve the functions of primary care, and whether they clearly specify the roles and interrelationships between primary care and specialist physicians.

Nurse Historical Background

Started in 1854. Nightingale needed to deal with was finding qualified nurses. The second was convincing the military physicians that the care she and her nurses proposed to provide would not spoil the soldiers by "coddling the brutes." Third, Nightingale had to show that she had special skills and knowledge that, when incorporated into the management of sick and wounded soldiers, would lead to positive outcomes that could benefit the war effort. The nursing reforms she introduced eventually reduced hospital mortality from 60% to about 1%.

Public Health Contributions

State and local public health services, and indeed federal services, face many problems. The current state of affairs is still best summarized by the Committee on the Future of Public Health, which published its report in 1988 (IOM, 1988): Many of the major improvements in the health of the American people have been accomplished through public health measures. But the public has come to take the success of public health for granted. This nation has lost sight of its public health goals and has allowed the system of public health activities to fall into disarray. Public health is what we, as a society, do collectively to assure the conditions in which people can be healthy. Many problems demonstrate the need to protect the nation's health through effective, organized, and sustained effort by the public sector. The current state of our abilities for effective public health action is cause for national concern. We have slackened our public health vigilance nationally, and the health of the public is unnecessarily threatened as a result. Successes as great as those of the past are still possible, but not without public concern and concerted action to restore America's public health capacity. This [report] envisions the future of public health, analyzes the current situation and how it developed, and presents a plan of action that will, in the committee's judgment, provide a solid foundation for a strong public health capability throughout the nation. (pp. 1, 2) The committee's report is commended to those readers who are concerned with the future of public health in the United States. These observations are certainly still valid. If anything, the situation has gotten worse, as witnessed by the disorganized response to the 2001 anthrax outbreak.

COST OF PRESCRIPTION DRUGS COME UNDER SCRUTINY

The "correct pricing" of pharmaceuticals will become a bigger issue in order to control cost, including inpatient care, resulting from, for example, coronary events (e.g., Lipitor) and liver failure (e.g., new hepatitis cures, although expensive, are cheaper than transplants).

Compare classification of hospitals.

The AHA classifies hospitals as one of four types based on the primary function of its diagnostic and therapeutic services: · General: for patients presenting with a variety of medical conditions · Special: for patients who have specified medical conditions · Rehabilitation and chronic disease: for handicapped or disabled individuals requiring restorative and adjustive services · Psychiatric: for patients who have psychiatric-related illnesses In 2011, there were 4,973 community hospitals out of the 5,724 hospitals of all types. teaching hospital to refer to hospitals providing undergraduate or graduate education for medical students and medical house staff (interns, residents, and specialty fellows). The term was not applied to hospitals with teaching programs for other health care providers. Public General Hospitals . The public general hospital was defined by the Commission on Public General Hospitals of the AHA (Commission on Public General Hospitals of the AHA, 1978, p. v) as "short-term general and certain special hospitals excluding federal (those operated by the Department of Defense and the Department of Veterans Affairs), psychiatric, and tuberculosis hospitals that are owned by state and local governments." Public general hospitals provide care for many persons unable to be treated elsewhere: the poor, the uninsured, the homeless, alcoholics and other substance abusers, the disruptive psychiatric patients, and prisoners. Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail.action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 09:55:20.

Administration for Children and Families

The Administration for Children and Families (ACF) works in partnership with states and communities to provide critical assistance to vulnerable families while helping families and children achieve a path to success. ACF programs work to find safe and supportive homes for abused children, counsel newly arrived refugees as they begin their new lives in America, and work to remove and provide opportunities to troubled teens living on the streets. Examples of programs and the percentage of the 2014 budget allotted to each program under the ACF includes Temporary Assistance for Needy Families (TANF; 33%), Head Start (16%), Foster Care and Permanency (14%), Child Care and Development (11%), Child Support (8%), LIHEAP (6%), Social Services Block Grant (SSBG; 3%), and Early Learning Initiative (3%). ACF has approximately 1,500 employees.

Agency for Healthcare Research and Quality (AHRQ)

The Agency for Healthcare Research and Quality (AHRQ) "supports research on health care systems, health care quality and cost issues, access to health care, and effectiveness of medical treatments. It provides evidence-based information on health care outcomes and quality of care" (DHHS, 2015a). It is designed to improve the quality of health care, reduce its cost, improve patients' safety, address medical errors, and broaden access to essential services.

A HEALTH INFORMATION EXAMPLE: NATIONAL HEALTHCARE SAFETY NETWORK

The CDC developed an Internet-based data collection and information retrieval system called the National Healthcare Safety Network (NHSN) that became available in 2005. This network is an expansion and enhancement of current surveillance and monitoring capabilities, and once implemented will replace three existing CDC surveillance systems: NNIS, the National Surveillance System for Health Care Workers, and the Dialysis Surveillance Network (CDC, 2005b). The goal is to create a common interface web-based system for accumulating, exchanging, and integrating relevant information and resources among stake holders, in an effort to support local efforts to promote patient safety. The two main aspects of the network are reporting of adverse events— including nosocomial infections— and disseminating information on preventing such events. Ultimately, the CDC aims to work with other public health agencies to create a national system integrating data from a variety of surveillance systems into a national aggregate data repository through which health care providers and federal, state, and private stakeholders can exchange data and retrieve information. In the beginning, however, the system will be restricted to providers submitting data in the areas currently covered by the three systems identified earlier, with the CDC acting as the central repository.

Centers for Disease Control and Prevention (CDC)

The Centers for Disease Control and Prevention (CDC) is the national public health agency primarily responsible for prevention efforts. Its programs are aimed at preventing and controlling disease and personal injury, directing foreign and interstate quarantine operations, developing programs for health education and health promotion, improving the performance of clinical laboratories, and developing the standards necessary to ensure safe and healthful working conditions for all working people. Through the NCHS, the CDC collects and publishes a variety of vital health and health services data. It maintains the nation's reference laboratories and supports laboratory training programs.

Centers for Medicare and Medicaid Services.

The Centers for Medicare & Medicaid Services (CMS) administer the largest insurance programs in the country, with a 2014 budget of approximately $850 billion. Medicare provides publicly financed health insurance for more than 54 million elderly and disabled Americans, and Medicaid, a program administered jointly by the federal government and the states, provides publicly financed health coverage for approximately 57.4 million low-income earner persons and nursing home coverage for low-income earner elderly adults. CMS also administers the CHIP that covers more than 8 million children. Although primarily considered a health care insurance program for low-income earner people, Medicaid-reimbursed services may also include such public health activities as early and periodic screening, diagnostic, and treatment (EPSDT) services for children, family planning services, cancer screening, school health services, and adult immunizations. Further, Medicaid payments also support public health providers, such as health centers, public hospitals, community mental health providers, and STD clinics, which are dependent on Medicaid revenues to sustain their operations (CMS, 2009, 2105; DHHS, 2015a).

Department of Defense (DOD)

The DOD oversees the health services of the various branches of the military through the Military Health System. Each of the armed forces— the Army, Navy, Air Force, and Marines— has its own network of health facilities: hospitals, clinics, and field posts (Assistant Secretary of Defense for Health Affairs, 1990, 1996, and the website). All DOD health personnel are members of the military and salaried according to their military ranks (without relation to the specific services they render). The same basic structure prevails in times of war or peace. Health promotion and disease prevention are emphasized and integrated with the delivery of treatment services. Through both its own facilities and contracting arrangements with civilian providers, DOD provides health services to members of the armed forces, their dependents, surviving dependents of service people killed while on active duty, and military retirees and their dependents. Servicemen and women are eligible for retirement benefits after a minimum of 20 years of service. The health services part of that package is paid in addition to the VA benefits for which they may be eligible. An unusual aspect of military medical departments is that they are charged not only with providing a full range of direct health services but also with providing for the environmental health and protection of their military communities. This unification of administrative responsibility for personal and community preventive and treatment services is rarely found elsewhere in the U.S. health care delivery system. Mission Statement: Our mission is to provide the military forces needed to deter war and ensure our nation's security.

SQ 1) Describe the role of the Department of Health and Human Services in health care in the United States.

The Department of Health and Human Services in health care in the United States has a role to enhance the health in the people of the U.S. this is by providing services in advancing medicine, health, and services to help U.S. citizens have the health care they need. They have also made it so that health care is provided to the people at a more affordable price. There is multiple health programs that have something for almost everyone at an affordable price.

Health Resources and Services Administration (HRSA)

The Health Resources and Services Administration (HRSA) runs the direct service programs of the DHHS for "medically needy" persons. Primarily through community and migrant health centers serving more than 19 million people and more than 77 million patient visits in 1,124 organizations across more than 8,100 service sites, HRSA supports efforts to increase the number and diversity of health care professionals caring for the underserved and vulnerable. These include low-income populations, the uninsured, those with limited English proficiency, migrant and seasonal farmworkers, individuals and families experiencing homelessness, and those living in public housing.

Health Resources and Services Administration (HRSA)

The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, is the primary federal agency for improving health care to people who are geographically isolated, economically or medically vulnerable. Mission: To improve health and achieve health equity through access to quality services, a skilled health workforce, and innovative programs.

Indian Health Service

The Indian Health Service serves Native Americans and Alaska Natives. It provides health care for about 2.2 million Native Americans and Alaska Natives, out of an estimated 3.7 million living in the United States (Indian Health Service [IHS], 2015a). In 2014, there were 44,677 inpatient admissions and 13.2 million outpatient visits (IHS, 2015b). The IHS is operated independently of other health care systems. "Most IHS funds are appropriated for American Indians and Alaska Natives who live on or near reservations or Alaska Villages (IHS, 2015a)." Congress also has authorized funding to support programs that provide some access to care for those who live in urban areas. Health services are provided directly by the IHS, through tribally contracted and operated health programs, and through services purchased from private providers. The federal system consists of 28 hospitals, 62 health centers, and 25 health stations. In addition, 33 urban Indian health projects provide a variety of health and referral services. The IHS clinical staff consists of approximately 2,480 nurses, 750 physicians, 700 pharmacists, 670 engineers/sanitarians, physician assistants/nurse practitioners, and 280 dentists, with a total number of employees equaling about 15,370, 69% of whom are American Indian/Alaska Native. The IHS also employs various allied health professionals, such as nutritionists, health administrators, and medical records administrators.

The Iron Triangle

The Iron Triangle is a term referring to three aspects that affect every decision about health care delivery - cost, access,choice, and quality. Cost includes such things as the amount paid for services, deductibles and co-pays, workers' salaries, technology, physical structures of facilities, research, pharmaceuticals, diagnostics and supplies... the list goes on and on. Quality involves patient outcomes (did the patient get better or die, have correct treatments/procedures, was the care timely.) Access includes whether services are available to patients and providers, geographically and financially. Choice refers to the patient's ability to pick their provider, a provider's ability to prescribe the preferred medication/order the chosen test and a payer's preference for reimbursement. Citizens of the US are VERY used to having choices!

INTERCONNECTING CLINICANS

The ONC initiative is based on patient records, and the second goal of the initiative is to provide access to patient health information in any health care setting, any place in the United States: The current practice of using separate paper files for one patient in multiple clinical settings is limiting and can compromise the quality of health-care received. Conversion to an EHR system is necessary but not sufficient to solve the portability problem. That's because each clinician or medical practice may purchase an EHR system from different vendors, which may not be compatible with one another. Unless EHR systems can communicate, they are simply islands of data where patient information does not flow seamlessly from one clinical setting to the next. Without clinicians' ability to exchange information with one another electronically, whether it is across town or across the country, patients' information may not be readily available when and where it is needed. To remedy this, an interoperable system based upon a common architecture must be developed. Patient records would then be available electronically virtually anywhere in the country. (DHHS, 2006, p. 1) The ONC strategy to create a national health care information network that can be accessed by any health care provider is to foster the development of RHIOs; develop a common set of communication standards to be used by the RHIOs through a National Health Information Network (NHIN); and apply the same standards as developed for the private health care sector to government-run health care.

PERSONALIZING HEALTH CARE

The ONC's third goal is to equip patients to participate actively in their own health care and in health care decision making through the development of a national health information system. Innovations in technology are emerging to give patients electronic access to their health record and the ability to gather specific information tailored to their illnesses, chronic conditions and health characteristics. Widespread adoption of these innovations, via a concept known as a Personal Health Record (PHR), will revolutionize consumer health care decision-making. (DHHS, 2006, p. 1) The ONC's strategy for facilitating patient participation in their own health care involves promoting the use of PHRs, stimulating informed consumer choice, and encouraging the use of telehealth systems to improve the quality and cost-effectiveness of health care in rural and underserved areas. The PHR is an electronic application through which individuals can maintain and manage their health information (and that of others for whom they are authorized) in a private, secure, and confidential environment . . . . For example, a PHR can be used to effectively synthesize an abundance of health information and tailor it to a patient's specific needs. (DHHS, 2006, p. 1) In order to stimulate informed consumer choice, the ONC supports providing patients or potential patients with information about the quality of their health care providers and organizations and the clinical effectiveness of treatments. The ONC supports and will promote "efforts in the federal government and elsewhere to develop useful clinical performance measures in hospitals, nursing homes, home health agencies, and other settings of care."

POPULATION HEALTH

The ONC's third goal is to equip patients to participate actively in their own health care and in health care decision making through the development of a national health information system. Innovations in technology are emerging to give patients electronic access to their health record and the ability to gather specific information tailored to their illnesses, chronic conditions and health characteristics. Widespread adoption of these innovations, via a concept known as a Personal Health Record (PHR), will revolutionize consumer health care decision-making. (DHHS, 2006, p. 1) The ONC's strategy for facilitating patient participation in their own health care involves promoting the use of PHRs, stimulating informed consumer choice, and encouraging the use of telehealth systems to improve the quality and cost-effectiveness of health care in rural and underserved areas. The PHR is an electronic application through which individuals can maintain and manage their health information (and that of others for whom they are authorized) in a private, secure, and confidential environment . . . . For example, a PHR can be used to effectively synthesize an abundance of health information and tailor it to a patient's specific needs. (DHHS, 2006, p. 1) In order to stimulate informed consumer choice, the ONC supports providing patients or potential patients with information about the quality of their health care providers and organizations and the clinical effectiveness of treatments. The ONC supports and will promote "efforts in the federal government and elsewhere to develop useful clinical performance measures in hospitals, nursing homes, home health agencies, and other settings of care."

Substance Abuse and Mental Health Services Administration (SAMHSA)

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities. Mission: To reduce the impact of substance abuse and mental illness on America's communities.

Substance Abuse and Mental Health Services Administration

The Substance Abuse and Mental Health Services Administration (SAMHSA) works to improve the quality and availability of substance abuse prevention, addiction treatment, and mental health services. SAMHSA provides funding through block grants to state and local governments to support substance abuse and mental health services, including treatment for serious substance abuse problems or mental health problems; supports educational programs for the general public and health care providers; improves substance abuse prevention and treatment services through the identification and dissemination of best practices; and conducts surveillance and monitoring of the prevalence and incidence of substance abuse.

SQ 1) Based on the U.S. Constitution, what do you think the proper role of government in the health care and why?

The U.S. Constitution does not state that there is a specific right to the health care system. But in my opinion, I think that there is some benefit to them being involved. I do think that there is some benefit to the government being involved. Such as with the Legislative branch ensuring that there is health care for everyone and protection to ensure that everyone has a right to some sort of health care. I think this is a proper role. I also agree that the Executive Branch should ensure that there is health care since the chapter states that the executive branch was the "government" of the chapter. Since it makes sure that everything is regulated. If the government was not involved there would not be certain things such as Medicaid to help insure that low income families would have universal health care. I think that the proper role of the government should ensure that everyone has access and the government has done some good in making it so that this is in place. I do not agree with some of the prices since it makes it hard for people such as diabetics to get the medication needed but there are some policies being put in place to make this happen. I do think that the government is slow moving in this but as long as they are taking action in some way I am happy.

Summery for Government money

The United States spends more on health care than any other country in the world, both on a gross basis and on a per capita basis. Further, the United States has a uniquely complex financing and payment system (as demonstrated by the information in this chapter). As some have assessed, we creakily crank dollars through the system, which requires enormous amounts of eligibility determination, benefit checking, coinsurance/deductible calculation/billing/collection, pre utilization authorization, utilization review, and so on (Himmelstein & Woolhandler, 2001). Mountains of paperwork are created, astronomical voice and fax/telephone costs are incurred, and untold amounts of computer time and space are used. Huge numbers of staff are required to carry out these activities. In addition to the high cost of administration, the U.S. health care system still leaves many people without health insurance and, therefore, with reduced access to health care. In 2013, more than 41 million Americans had no health care coverage of any kind (Kaiser Family Foundation, 2015). This lack of health insurance has many negative consequences, ranging from personal anxiety, to increased use of emergency rooms (often meaning that care was deferred past the point where it might have been routine— and cheap— to where it was complex and expensive, with the delay leading to avoidable complications), to growing personal bankruptcy rates (C. Hoffman et al., 2001). This is projected to change under the Patient Protection and Affordable Care Act passed under President Obama in 2010. See Chapter 9 for a discussion. In the next chapter, we discuss the performance— quality, equity, and efficiency— of the complex system that we have developed for providing health care in the United States. This is followed by chapters on the history of attempts to reform the system and projections about the future.

Agency for Healthcare Research and Quality (AHRQ)

The branch of the US Public Health Service and Federal agency that supports general health research and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services. Mission: To improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

Summery

The bulk of the need for medical care and for the provision of health services occurs in the ambulatory setting. In the United States, a disproportionate share of health care resources is devoted to inpatient care, both acute and long term. Given the current profile of disease and disability in the United States, it is obvious that significant improvements in the health of the American people could be achieved by the widespread implementation of known health-promotive and disease-preventive measures in the ambulatory setting (National Prevention Council, 2011). This is the central element of comprehensive primary care and would relieve the reliance on inpatient medical care. Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail.action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 12:30:33.

Department of Health and Human Services

The central, though not only, federal agency responsible for health and health care in the United States is the DHHS. Its mission is "to enhance the health and well-being of Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services" (DHHS, 2015a). Through 11 operating divisions, DHHS administers more than 115 health-related programs in a wide range of areas, including health and biomedical research, epidemiology and surveillance, disease prevention and immunization, food and drug safety, providing access to primary health care for certain populations, and bioterrorism response preparedness (DHHS, 2013). DHHS directly employs the full-time equivalent of approximately 77,865 people in 2015,and has a budget of $1,092.9 billion in 2016 (DHHS, 2015b). Out of the 11 operating divisions within DHHS, eight are components of the U.S. Public Health Service (Schmeckebier, 1923). There are three staff offices within the Office of the Secretary, which are also designated components of the U.S. Public Health Service and which operate to coordinate the agency's public health activities. These operating divisions and staff offices themselves each contain many subagencies and offices, administering hundreds of programs within DHHS. Table 4.1 lists the operating divisions and staff offices of the U.S. Public Health Service and their respective missions. As Table 4.1 indicates, the scope of activities and services undertaken by the DHHS is vast, and indeed, many of the identified subagencies and offices have their own branches and divisions, each with its own mission and program responsibilities. A comprehensive discussion of the activities and programs of the DHHS agencies is far beyond what can be accomplished here. What follows should not, by any means, be considered an exhaustive description of the agencies discussed, but is rather intended to give an idea of some of the key programs and activities of the DHHS agencies, and how they relate to the health care system in the United States. Collectively, the 11 operating divisions of the DHHS carry out a variety of functions: regulation, direct provision of personal and community health services, provision of financial support for a variety of health services through grants and contracts, direct biomedical research, and provision of the principal federal support of biomedical research in nongovernmental agencies. A brief description of these divisions follows.

IMPACT OF NEW TECHNOLOGY

The continual pursuit of improved quality and efficiency in the health care system will drive application of technological innovations and policy changes. Technological improvements will continue to address cost or cost and quality. ■ ■ Automation will start to take hold— starting with eliminating lower level jobs like phlebotomists and coders while accelerating/supplementing higher level jobs like RN and physicians, for example, through computer-assisted diagnosis, computer-assisted documentation, and continuous patient assessments. ■ ■ Genomics and proteomics will lead to increasingly personalized treatments and protocols in the short term and begin to revolutionize the approach to medicine and health in general over longer time periods. ■ ■ We will start growing what we used to manufacture. This is already happening with knee implants. ■ ■ We will start injecting stem cells, nanobots, or other biologics to regrow new body parts and replace surgery. ■ ■ Medical devices and drugs will become so personalized that they will need to be evaluated like a medical procedure— effectiveness of an approach rather than a particular chemical compound or manufactured device. ■ ■ Shorter term new technology and understanding will allow more "site of service" optimization: hospital -> outpatient -> home care -> telemedicine.

Centers for Disease Control and Prevention (CDC)

The primary federal agency that conducts and supports public health activities in the United States. The CDC is part of the US Department of Health and Human Services and another division of the USDHHS and concerned with causes, spread, and control of diseases. Mission: Collaborating to create the expertise, information, and tools that people and communities need to protect their health- through health promotion, prevention of disease, injury, and disability, and preparedness for new health threats

Risk Transfer and Good Intentions

The different payment models can be arranged along a continuum representing the financial risk borne by the buyer and the risk borne by the provider. If the payment model with which the patient pays is different from the payment model under which the provider operates (as is possible in a system with third-party payers such as the current U.S. health system), then the possible combinations can be represented as a matrix (see Figure 5.5). With each combination, any risk not borne by the provider or patient is borne by the third-party payer. One could expect a third-party payer to react to this risk by excluding people or conditions, rejecting charges, capping fees, or otherwise capping coverage and raising premiums. On the other hand, even when the payment methods match (e.g., the patient and the provider operate under a fee-for-service contract), either side may wish to use an intermediary. The introduction of health savings accounts (HSAs) has essentially created an opening for a different type of institution in health care that starts to resemble something like American Express as opposed to United Health. So one sees banks— experts in low-risk, high-volume transactions such as managing payments for product purchases— entering the health care market. It should be noted that how we pay for health care has both short-term and long-term implications. The system of payment affects how the principals act in the system today, but also who and where the principals are tomorrow. There is no shortage of physicians in training who vie for residencies in dermatology or cosmetic surgery, but pediatrics is always in need. A simple capitation system will encourage physicians (and other providers) toward healthier patients. Similarly, a system rewarding outcomes may encourage physicians away from riskier cases. The challenge of rewarding for process consistency is that nearly all best practices are contraindicated in some populations.

Definition of Nursing

The essential features of professional nursing are considered to be: ■ ■ Provision of a caring relationship that facilitates health and healing ■ ■ Attention to the range of human experiences and responses to health and illness within the physical and social environments ■ ■ Integration of objective data with knowledge gained from an appreciation of the patient's or group's subjective experience ■ ■ Application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking ■ ■ Advancement of professional nursing knowledge through scholarly inquiry ■ ■ Influence on social and public policy to promote social justice.

Department of Labor (DOL)

The federal agency responsible for administering and enforcing a large quantity of federal labor laws, including, but not limited to, overtime pay, child labor, wages and hours, workplace health and safety, FMLA, and various other employee rights.

Indian Health Service (IHS)

The federal agency within HHS that is responsible for providing federal healthcare services to American Indians and Alaskan natives. Mission: To raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.

Fee-for-Services

The fee-for-service method is common when the scope of work is clear to both sides. It is the oldest form of payment for health services and the predominant system of paying physicians, dentists, and private providers in the Other Professional Services category of the NHE. For example, a dentist will typically have a set price for a cleaning and checkup. If additional services are needed, those will be performed at essentially published prices. In such a system, the risk of inefficiency is borne by the provider and the risk of bad advice is borne by the customer. Whether a root canal requires 1 hour or 2 hours to perform and whether or not a root canal is the best use of the patient's money, the dentist receives the same payment. The local market and the dentist's reputation drive the rates he or she can charge. According to some observers (Jonas, 1978; Roemer, 1962), in the past this piecework system was a major cause of many of the observed problems in the health care delivery system. Although the patient's risk that he or she overpays for a service is reduced, such systems do not reward the providers for better quality service. Nor do they reward the provider for steering the patient toward more efficient services. A frequent complaint is that preventive medicine is completely ignored.

Medicare

The first national social insurance program to finance medical care in the United States was established by Congress in 1965 as part of President Lyndon Johnson's "Great Society" program. 3 Called Medicare , it is authorized by Title XVIII of the Social Security Act Originally, it provided payment for some health services for persons 65 years of age and older who were eligible for Social Security or Railroad Retirement benefits, whether they took them or not. In 1973, its coverage was broadened to include those permanently disabled workers and their dependents who were eligible for old age, survivors' and disability insurance under Social Security, as well as persons with end-stage renal disease. Medicare has four parts: hospital insurance (Part A), which also covers skilled nursing facility care on a very limited basis, as well as hospice and home health care; supplementary medical insurance (Part B), which covers physician and certain other health professional services, hospital outpatient care, and certain other services; Medicare + Choice (Part C), which permits Medicare beneficiaries to enroll in MCOs; and Medicare Prescription Drug Coverage (Part D), which was designed to lower the costs of prescription medication for Medicare beneficiaries. Medicare Part A is funded primarily from Social Security taxes, whereas about two thirds of Part B is funded from general revenues, with the balance coming from enrollee premium payments. Medicare prescription drug coverage is funded through premiums. Medicare is operated by the CMS (formerly called the Health Care Financing Administration) of the U.S. Department of Health and Human Services. Its administrative costs are remarkably low compared to those of the private health insurance sector, ranging from 1% to 2% Medicare Part D, which was part of the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003, began on January 1, 2006. Part D provides eligible patients with prescription drug benefits, designed to reduce the cost of medications. Coverage is provided through private entities, both stand-alone prescription drug plans (PDPs) and the more comprehensive Medicare Advantage (MA) plans. The financial risk of the program is shared by both private entities and the government. Enrollment into Medicare Part D is voluntary for those who did not previously receive drug coverage through Medicaid. The population subset that is eligible for both Medicaid and Medicare is known as "dual eligible." Before 2006, their drug coverage was provided by the Medicaid program. In the beginning, beneficiaries had the option to choose which plan best suited their needs. Later, they were automatically enrolled in what the government decided was the appropriate plan. For those not covered under dual-eligible status, there is a monthly premium, estimated to be $35 in 2006. This premium is in addition to the annual premium for Medicare Part B (about $420). Under the plan's current structure, there is a $250 deductible to be paid by the individual. After the deductible is paid, Medicare pays 75% of prescription drug costs, up to $2,250 in total drug costs. Between $2,250 and $5,100, Medicare Part D provides no coverage. This gap in coverage is known as the "doughnut hole." After the gap, Medicare pays 95% of drug costs. In every category, the individual is expected to pay the remaining portion of costs, either out-of-pocket or through additional private insurance coverage. The deductibles, premiums, and limits will increase annually. Most Medicare beneficiaries use providers of their choice. Physicians are paid on a fee-for-service f basis, according to a fee schedule constructed on the so-called resource-based relative value system (RBRVS). In the mid-1980s, it replaced the old inflation-stimulating "usual and customary fee" system. Because the "usual and customary fees" were set by the physicians themselves, the inflation factor was built in. Unfortunately, as payments to physicians began to decline in the early 2000s as a result of the federal Balanced Budget Act (BBA) of 1997, an increasing number of physicians refused to accept Medicare fees as payment in full. In this instance, the physician sees only those Medicare patients who agree to accept responsibility for the total charges and then submit the bill to the Medicare program to obtain whatever reimbursement they can. Hospitals are reimbursed on an episode-of-care basis, the amount of payment for each case determined by a formula based on a fiscal construct called the diagnosis-related group (DRG), one form of the prospective payment system (PPS). Managed care was introduced into the Medicare program in the mid-1990s. However, MCOs claimed that Medicare reimbursement levels were too low (Moon, 2001), and, as a result, they dumped almost 1 million beneficiaries on January 1, 2001. In 2013, total Medicare expenditures were over $586 billion (see Table 5.2), covering some of the health care costs for about 52 million enrollees in one or both of Parts A and B. When Medicare began on July 1, 1966, approximately 19 million people enrolled. In 1998, although about 75% of Medicare enrollees incurred some expenses, about 50% of the total paid for care went to only 6% of beneficiaries who received care (C. Hoffman et al., 2001, pp. 32, 93). Medicare financed 45% of all spending for hospital care and 22% of physician services costs in 2013 (CMS, 2014). As noted by Meier and Morrison (2002), "In 2002, 50 percent of deaths of Medicare beneficiaries occurred in hospitals, often after stays in intensive care units, visits to multiple physicians in the months before death, and enormous expenditures for treatments intended to prolong life" (p. 1087). Looking toward the mid-21st century, the Medicare program is seriously in need of rescue and reform (Igelhart, 1999c; Moon, 2001). The "baby boomers"—those people born in the immediate post- World War II era— became eligible for Medicare starting in 2010, whereas the number of working people available to finance the system through the payroll tax that presently supports it will, in relative terms, continue to decline. Medicare covers that part of the population that requires the most medical services (i.e., the elderly), but it is financed narrowly by the limited payroll tax.

U.S. Health Care System

The five components of health care systems— facilities, workforce, suppliers of medical products, educational and research organizations, and financing mechanisms— are organized to provide health services. In every system, there is some kind of organizational structure that enables the system's components to interact and function to produce health services for the people. Typically this requires organizations that function as health care payers, health care providers, health care policy makers, or some combination of these. These organizations or entities may be governmental health authorities and other agencies of government with health care functions (government sector), private, nonprofit health care organizations, which includes the voluntary health care agencies and professional associations, or private, for-profit enterprises with health care functions.

Components of the U.S. Health Care System

The five main major components are: Facilities, workforce, training and research, suppliers of medical products, and financing. As the physicians have shifted to joining larger organizations, ambulatory care, or care provided to patients not expected to sleep at an institution, has shifted to standalone (but hospital-owned) physician practices, ambulatory clinics that are part of hospital facilities, Federally Qualified Health Centers (FQHC), and community mental health centers. The other major class of institutions are those housing and caring for patients in bed, of which the hospital is the most familiar. Acute care hospitals are also the largest single component of health care expenditures (see Chapter 5). Other inpatient facilities include hospices, skilled nursing facilities and other nursing facilities, and intermediate care facilities, including those for the mentally retarded (Centers for Medicare & Medicaid Services [CMS], 2015). There are also disease-specific and other specialty hospitals.Health care and social assistance consists of three subgroups: (a) hospitals; (b) health services like offices of health practitioners, outpatient care centers, home health care services, other health care services, nursing care facilities, residential care facilities; and (c) social assistance like individual and family services, community food and housing, and emergency services, vocational rehabilitation services, and child day care services. The health care and social assistance sector comprises establishments providing health care and social assistance for individuals. A variety of medical products, including equipment and pharmaceuticals, are required in the health care system. They are generally categorized as prescription drugs, the largest of the categories; durable medical equipment; and other nondurable medical products.

ORGANIZATIONS WITH MAJOR INFLUENCE ON HEALTH CARE QUALITY

The following section describes the efforts of public and private organizations to improve the quality of health care in the United States. These efforts are increasingly collaborative. Many businesses that pay for the health care of their employees have banded together. Public initiatives are increasingly coordinated. And, private- public partnerships have developed. However, it is difficult to say which organizations are the most influential. Clearly, The Joint Commission and the Centers for Medicare & Medicaid Services (CMS), as one of the largest payers of health care services in the country, are extremely influential. However, private organizations and other public agencies have very important roles, as well. The impact of these significant efforts on the quality of U.S. health care is yet to be determined.

Time and Materials

The hourly payment method, common in service industries, is often referred to as time and materials. In this case, a provider would be charged a fixed hourly rate covering all the costs except agreed-on materials, which would be billed as incurred. For example, a residential electrician might pass along all costs for fixtures and breakers and charge $85 per hour for his time, which then must cover his vehicle, all his tools, any assistants he might employ, and so forth. Time and materials tends to be the system of choice in cases where the scope of work is not clear to either party. Per diem (by the day) reimbursement remains a very common payment method for hospitals (Kaiser Family Foundation, 2002). Although such a system encourages the hospital to work hard to minimize overhead expenses, payers will always worry that the hospital is not looking for ways to increase efficiency.

The Judiciary

The judiciary generally supports the work of the other two branches of government. The judicial branches at the three levels of government have important powers relating to health and health services. In the criminal law arena, working in concert with the law enforcement arms of the executive branches, under the authority granted to them by their respective legislatures, they can try apprehended transgressors of the criminal law and determine punishment for those successfully prosecuted. For example, although it is a state legislature that creates the licensing law for physicians and the executive branch that administers it, it is the judicial system that determines the guilt or innocence of a person charged with "practicing medicine without a license." The criminal justice system also plays a vital role in safeguarding the public's health. For example, it enforces sanitary protection and pollution control legislation, with criminal sanctions if necessary. In the civil arena, the judicial system handles disputes arising from the provision of health services, for example, through the process of malpractice litigation. The judicial system adjudicates contract cases arising from health care system disputes, such as those between providers or patients, on one side, and a third-party payer on the other. It protects the rights of individuals under the due process and equal protection clauses of the Fifth and Fourteenth Amendments to the Constitution. Together, then, the judicial and executive branches form the civil and criminal justice systems, at the federal, state, and local levels.

Physicians Historical Background

The profession of medicine in America has changed dramatically over the course of history. The role, training, and expectations of pre-Revolutionary War physicians are practically unrecognizable to us today, The bulk of the practicing physicians in the colonies— including all of the independent New Englanders— were apprentice trained. Some had undergraduate degrees, whereas others were no more than 15 years old when starting their medical careers. Benjamin Rush noted that the only prerequisite for a "doctor's boy" was the ability to stand the sight of blood! His teacher was likely to be a prominent physician-surgeon, well qualified to guide the student through the maze of anatomy, osteology, the compounding of medicine, surgery, and the writings of Hippocrates. Toward the end of the 3- to 6-year apprenticeship, the doctor's boy was doing his own bloodletting, tooth-pulling, wound dressing, and some minor surgery. His certificate of proficiency gave the same practicing privileges as a medical student from the continent.

Major features of the Obama Health Plan

The main features of the bill include (Davis, 2010, pp. 5- 7): New federal insurance market rules that prohibit restricting coverage or varying premiums based on health, set limits on the share of private premiums going for nonmedical costs, and establish essential standard benefit packages that guarantee beneficiaries a comprehensive array of services with limits on levels of cost-sharing. New health insurance exchanges that will more efficiently pool risk, lower administrative costs, and provide eligible individuals and small businesses a choice of affordable health plans. Affordability provisions for lowand middle-income families , including an essential standard benefit package, premium assistance on a sliding scale up to four times poverty income (about $88,000 for a family of four), and expansion of Medicaid eligibility up to 133% of the federal poverty level (almost $30,000 for a family of four). A commitment to shared responsibility that preserves employer-sponsored insurance, provides health insurance tax credits to small businesses, assesses a contribution from larger businesses whose employees receive government-financed premium subsidies, and requires that individuals have coverage. Improvements to Medicare prescription drug benefits , including $250 rebates for seniors falling into the "doughnut hole" in 2010 and elimination of that coverage gap by 2020. Creation of a new long-term care financing program to support community living for the disabled. Investment in a stronger primary care foundation , one that includes increases in payment for primary care under Medicare and Medicaid, incentives for practices to organize as patient-centered medical homes providing more accessible and coordinated care, and investment in primary care training and expansion of community health centers and the National Health Service Corps. Establishment of an innovation center within the Centers for Medicare & Medicaid Services to rapidly test and spread effective payment methods that reward quality of care, rather than volume of services. Additional payment and system reform provisions encourage accountability for patient outcomes and use of medical resources, and provide incentives for productivity improvement. Creation of an Independent Payment Advisory Board with the authority to make recommendations for reducing cost growth and improving quality in both the Medicare program and the health system as a whole. Investment in the infrastructure required for a high-performance health system , including publicly reported information on quality, cost, and performance of providers and insurers; use of modern information technology in medical care and health insurance; and national strategies and policies on disease prevention, public health, quality, safety, and the health care workforce.

FEDERAL AGENCIES

The major federal government agencies that focus on ensuring and improving the quality of health care are described next. Each of these agencies has been discussed previously in Chapters 5 and 6, but the following discussion focuses on their role in ensuring quality and evaluating health systems performance. Centers for Medicare & Medicaid Services. The CMS is a federal agency within the U.S. Department of Health and Human Services. (Until 2001 it was known as the Health Care Financing Administration or HCFA.) CMS has several offices and initiatives that focus on improving the quality of health care, including the Office of Clinical Standards and Quality, the Quality Initiatives (QIs), and the Medicare Health Outcomes Survey (HOS). Because Medicare and Medicaid pay for so much health care in the United States, their ability to influence quality throughout the health care system is enormous. The Office of Clinical Standards and Quality (OCSQ) serves as the focal point for all quality, clinical and medical science issues and policies for CMS programs . . . . It coordinates quality-related activities with outside organizations. OCSQ also monitors the quality of Medicare and Medicaid programs and evaluates the success of interventions. (CMS, 2007a, p. 1) The overall goal of the QI is to improve the quality of services for Medicare and Medicaid recipients through methods of provider accountability and public disclosure. The QI was launched nationally in 2002 with the Nursing Home QI (NHQI) and expanded in 2003 with the Home Health QI (HHQI) and the Hospital QI (HQI). In 2004, the Physician Focused QI, which includes the Doctor's Office Quality Project, was developed. In 2004, the QI was expanded to officially include kidney dialysis facilities. The End Stage Renal Disease (ESRD) QI promotes ongoing CMS strategies to improve the quality of care provided to ESRD patients. In 2006, CMS launched the Physician Voluntary Reporting Program (CMS, 2007b). In 2009, CMS estimated that almost all settings covered by Medicare were covered by quality measures (CMS, 2009). CMS, in collaboration with the National Committee for Quality Assurance (NCQA), launched the Medicare HOS in 1998 to study the outcomes of Medicare-managed care. The Medicare HOS is being used as part of the effectiveness of care component of the Health Plan Employer Data and Information Set (now called the Healthcare Effectiveness Data and Information Set (HEDIS)]. The HOS measure includes physical and mental health outcomes and risk adjustment techniques. In addition to health outcomes measures, the HOS is used to collect the Urinary Incontinence in Older Adults and Physical Activity in Older Adults HEDIS measures (CMS, 2007c). Agency for Healthcare Research and Quality. The AHRQ is the division of the U.S. Department of Health and Human Services charged with coordinating, conducting, and supporting research, demonstrations, and evaluations related to the measurement and improvement of health care quality. The AHRQ mission is "to improve the quality, safety, efficiency, and effectiveness of health care for all Americans" (AHRQ, 2007a, p. 1). AHRQ is charged with disseminating scientific findings about clinical practice guidelines and facilitating public access to information on the quality of health care. AHRQ research provides evidence-based information on health care outcomes; quality; and health care cost, use, and access. The information helps health care decision makers— patients and clinicians, health system leaders, purchasers, and policymakers— make more informed decisions and improves the quality of health care services. Beginning in 2005, AHRQ's "research agenda reflected a shift to emphasize the translation of research into practice" (AHRQ, 2007b, p. 1). Nearly 80% of AHRQ's annual budget of approximately $300 million is awarded as grants and contracts to researchers at universities and other research institutions across the country through its evidence-based practice centers and the National Quality Measures Clearinghouse (AHRQ, 2007c, 2007d). Researchers are funded to conduct systematic, comprehensive analyses, and syntheses of the scientific literature and to develop reports and technology assessments based on the research-supported evidence (i.e., clinical practice guidelines). To ensure that report findings are translated into improvements in clinical practice, AHRQ enlists partners, such as specialty societies and health systems, which use the findings of evidence-based practice centers to develop tools and materials that will improve the quality of care. Centers for Disease Control and Prevention. The CDC is the nation's primary government agency for developing disease prevention and control initiatives and health-promotion and educational activities. In terms of health care quality, it has a particularly important role in the control of nosocomial infection. The DHQP undertakes initiatives in conjunction with other CDC divisions, such as the National Center for Infectious Diseases, when appropriate. The DHQP is charged with protecting patients and health care personnel and promoting safety, quality, and value in the health care delivery system (CDC, 2005a, 2012a). Among the DHQP priorities are the following: ■ ■ Measuring, validating, interpreting, and responding to data relevant to health care outcomes; health care-associated infections/antimicrobial resistance; related adverse events; and medical errors among patients and health care personnel (This priority is addressed primarily through the NNIS system discussed previously in this chapter.) ■ ■ Investigating and responding to outbreaks and emerging antimicrobial-resistant pathogens and infections among patients or associated with the health care environment ■ ■ Identifying and evaluating the efficacy of interventions designed to prevent health care-associated infections or antimicrobial resistance, related adverse events, and medical errors ■ ■ Promoting clinical microbiology laboratory quality. The CDC provides extensive information on infection control guidelines, infectious disease outbreak management, antimicrobial resistance, laboratory practice, sterilization and disinfection, and surveillance. The CDC further offers advice and consultation to health care providers or regional health departments on matters relating to infection control. It also operates a free rapid notification system through which time-sensitive e-mail messages about important health care events (e.g., outbreaks, product recalls) and publications (e.g., new health care guidelines) are sent to persons active in the prevention of health care-acquired infections and antimicrobial resistance. The CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal advisory committee made up of 14 external infection control experts who provide advice and guidance to the CDC regarding the practice of health care infection control, strategies for surveillance, and prevention and control of health care associated infections in U.S. health care facilities. One of the primary functions of the committee is to issue recommendations for preventing and controlling health care-associated infections in the form of guidelines, resolutions, and informal communications. HICPAC has issued practice guidelines on the following subjects: environmental infection control in health care settings; hand hygiene in health care settings; intravascular device-related infections; surgical site infections; isolation precautions; nosocomial pneumonia; and CAUTI. Along with the Get Smart for Healthcare: Know When Antibiotics Work Campaign, the CDC has an interagency task force on antimicrobial resistance, which partners with hospitals, state and local health departments, medical and professional associations, health insurers, private industry, continuing medical education organizations, and other health agencies to promote universal adoption of several practice recommendations concerning infection prevention, effective diagnosis and treatment, wise antimicrobial use, and transmission prevention designed to prevent antimicrobial resistance among patients. As part of this campaign, the CDC provides clinicians with information for preventing antimicrobial resistance among specific patient populations (e.g., surgical, children), including fact sheets listing the particular steps that should be taken to prevent resistant infections in targeted populations and materials for distribution to patients with tips on infection prevention. National Institutes of Health. The NIH is a primary source of funding for medical and behavioral research in the United States. An agency under the federal Department of Health and Human Services, the NIH funds a broad array of extramural projects, grants, contracts, and cooperative agreements conducted primarily by universities, hospitals, and other research institutions. Much of the patient-oriented research includes studies into the development of new technologies, human disease mechanisms, therapeutic interventions, and clinical trials. Other clinical research includes epidemiological and behavioral studies, outcomes research, and health services research. The NIH is the source of much funding for clinical outcomes studies that are used for evidence-based medicine and clinical practice guidelines.

Major Stakeholders in Health Care

The major stakeholders in the healthcare system are patients, physicians, employers, insurance companies, pharmaceutical firms and government. Insurance companies sell health coverage plans directly to patients or indirectly through employer or governmental intermediaries.

Occupational Safety and Health Administration (OSHA)

The mission of OSHA is to save lives, prevent injuries, and protect the health of America's workers. With the Occupational Safety and Health Act of 1970, Congress created the Occupational Safety and Health Administration (OSHA) to ensure safe and healthful working conditions for workers by setting and enforcing standards and by providing training, outreach, education and assistance. the Occupational Safety and Health Administration (OSHA) is part of the Department of Labor. OSHA uses criteria developed by the National Institute for Occupational Safety and Health (NIOSH), part of the CDC, to set national standards for occupational safety and health (Brock & Tyson, 1985). Since 1970, workplace fatalities have been reduced by more than 65% and occupational injury and illness rates have declined by 67%. At the same time, U.S. employment has almost doubled. Worker deaths in America are down— from about 38 worker deaths a day in 1970 to 12 a day in 2013. Worker injuries and illnesses are also down— from 10.9 incidents per 100 workers in 1972 to fewer than 3.3 per 100 in 2013 (OSHA, 2015). The major responsibilities of OSHA are to develop workplace health and safety standards, to enforce and gain compliance with the standards, to engage in education and training, to help the states in occupational safety and health matters (26 states have their own occupational safety and health programs), and to aid business in meeting OSHA requirements (OSHA, 2015). There are a few industries that are not covered by OSHA. For example, the health and safety of miners is the province of the Bureau of Mines in the Department of the Interior. Mission Statement: With the Occupational Safety and Health Act of 1970, Congress created the Occupational Safety and Health Administration (OSHA) to ensure safe and healthful working conditions for workers by setting and enforcing standards and by providing training, outreach, education and assistance.

Discuss historical background of hospitals

The most intensive care is provided in hospitals and, although less than 10% of the population will experience an overnight stay in a hospital, they accounted for the largest portion of U.S. health care spending (32%) in 2013 (National Center for Health Statistics [NCHS], 2015, Table 103). In this section, we provide an overview of the conditions typical of hospitalized patients, a brief historical background on this important health care sector, and then describe its current structure. The mold from which today's health care system was cast took its shape around 1850. There were still relatively few general hospitals or health care facilities of any type in either Great Britain (our most important medical organizational forebear) or the fledgling United States, but the institutional organization of health care was already firmly established. The physical separation, for the most part, as well as separate provision for administration and staffing of the curative services for acute, chronic, and psychiatric illnesses became firmly established in the 19th century. That very strong precedent continues to control the physical and administrative design of the health care delivery system even when all three components have a common source of support, as they do now in Britain. Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail.action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 09:47:38.

EFFICIENCY AND QUALITY OF HEALTH CARE

The organization of U.S. health care delivery evolved over the 20th century from solo practices and single hospitals to vertically and horizontally integrated health care delivery systems that may provide ambulatory, inpatient, long-term care, and home health care, as well as health insurance. The organizational changes described in this chapter have been prompted by the wish to improve the efficiency of health care delivery and the coordination of care. The form they have taken is again uniquely American in the mix of private and public involvement.

Matching Different Provider and Patient Payment Approaches

The other motivation for having third-party payers is to bridge the gap between how people want to pay for health care and how providers want to be paid. Although there is little need for a third-party payer in a case where a person wants to pay a fixed monthly amount for health care to a provider who is paid on a capitation basis and offers the entire range of medical services, in reality people do not usually have this option. More often, people obtain their health care from a variety of providers who may be operating under any one of those aforementioned models, and quite often an individual provider will offer services under multiple and differing charging models. A third-party payer adds value by converting a stream of monthly payments into a stream of service-driven or ailment-driven payments to providers.

Providers of Care: Module

The psychiatrist is a medical doctor focusing on diagnosing and treating the illness, using medical interventions. The psychiatrist can admit a client to an inpatient setting. The psychologist is also a doctor, but his/her doctoral degree is in psychology. This professional's focus in mental health is developing and interpreting psychological testing. These tests are given for a variety of reasons, but some help diagnose disease. Psychologists can treat clients, usually using counseling techniques. If medications are needed the client will be referred to a psychiatrist for medication management. Psychologists cannot admit a client to an inpatient setting. A psychiatric social worker is an individual whose education is in social work, with graduate work in psychiatric illness. This individual may treat clients with mental illness using counseling techniques. The mental health clinical nurse specialist has a basic nursing education in mental health nursing. These nurses can treat clients with mental illness, usually in group therapy but may also use individual counseling techniques. Registered nurses who work with mental health clients, usually do so in an inpatient setting and their main focus is administering and monitoring medication and addressing physical concerns. Mental health attendants/aides assist with physical care and supervision of clients in various settings. Primary care providers are usually considered "front line" in assessing and caring for those with non-severe mental illness.

Private Health Insurance

The salient feature of private insurance in the United States is that most people obtain it through their employer (or spouse's or parent's employer). One can almost say that employers (and employees, through their contributions to health insurance premiums) are the true payers in this case and that private insurance companies are the administrators of payments. Outside of employer-sponsored plans, private health insurance can be difficult to obtain because of the inherent problems of moral hazard and asymmetries of information discussed earlier. For example, a "Standard Individual [not part of a group] Point of Service" insurance plan to cover a family starts at more than $4,500 per month with some options exceeding $8,000 per month in New York County, even though the benefits are not more generous than a typical employer plan, which would cost far less to the same family (New York State Department of Financial Services [NYSDFS], 2012). About 61.8% of Americans age 14 to 65 have some type of private health insurance coverage (National Center for Health Statistics [NCHS], 2015, Table 111). This is a decrease from 76.8% in 1984 and 71.5% in 2000. Generally speaking, insurance companies are either for-profit or nonprofit. Blue Cross Blue Shield (BCBS) has been a major private health insurer since 1929. The BCBS system consists of 36 independent and locally operated BCBS companies, a federal employee program, and an association that serves the collective needs of BCBS plans and covers more than 106 million people— one third of all Americans. The BCBS system is the nation's oldest and largest family of health benefits companies. Nationwide, more than 96% of hospitals and 92% of professional providers contract with BCBS companies— more than any other insurer. The BCBS Association (BCBSA) owns and manages BCBS trademarks and names in more than 170 countries and territories around the world (BCBS, 2015). Originally, BCBS was entirely nonprofit, although a move to convert to for-profit status began for some BCBS companies in the mid-1990s (Cunningham & Sherlock, 2002). The commercial insurance companies, such as Metropolitan Life and Aetna, have always operated on a for-profit basis only. Some of their surplus of income over expenditures is paid to the owners of the company as profit. The private sector— through health insurance companies, out-of-pocket payments, and other sources— paid for about 51.6% of national health care consumption in 2013, down from about 59.6% in 1990, and 55.7% in 2000. Private health insurance companies alone paid for about 34.9% of national health care consumption in 2013. In 1970, this percentage had been about 23% and then slowly started to rise until it reached 34.6% in 1990, after which it stayed roughly constant.

SQ 3) Compare and contrast the six payment modes that are used to buy and sell health services?

The six payment modes that are used to buy and sell health services. There is: cost/cost-plus, hourly or time and materials, fee-for-service, fixed price, capitation, and value. The cost/cost-plus method is known as reimbursement. Many hospitals think of this as the patients paying the service plus a little more so that the hospital can profit for the services provided. Some people enjoy this method since there is transparency and they know where the fee is coming from. Hourly or time and materials is what many have in offices since there is a fixed hourly rate. This works when neither party know what should be charged for the services provided. This is a common method in hospitals, and it decreases the overhead, but some patients do not like this method since the patient does not know if the hospital is working hard to decrease the time that the patient is there, or if they are trying to increase the amount of money that they are getting. Fee-for-service. This method is more common when both parties know the scope of practice unlike the hourly or time and materials method. This method is common, but it is thought that is comes with problems since the payer does not know if they are overpaying for the service. Also, some providers do not like this method since there is no reward for the provider. This ignores preventative medicine as well. Fixed Price method: This is where there is a known price for the service. This is compared to the fee for service method. This method was founded for Medicare. The provider can sometimes be rewarded based on how well they have done, but sometimes the providers take advantage of this and over state the condition. Capitation: This is a fixed prepayment per person. This works well in some cases since the payment is the same no matter the number of services or what type. This does not promote long term health. The provider has a "global budget" this is a common form of payment for different institutions and clinics. The 'Global Budget" is thought to be predetermined based on last years spending. Value: This is a payment based on the services provided and the place is rewarded based on the services provided. This can be hard since the patient may have a hard time understanding the price of the services.

SURVEILLANCE AND DATA COLLECTION

The system will be divided into various adverse event modules, including d evice-associated adverse events, procedure-associated adverse events, and medication-associated adverse events. The infection data collected will be similar to that collected through the NNIS, but with important differences. Device-Associated Module. Currently, in the intensive care unit and high-risk nursery components of the NNIS system, data are collected on incidence rates and distributions for infections at all sites. In the NHSN system, infection data will initially be collected only for CLABSIs, catheter-associated urinary tract infections, ventilator- associated pneumonia, and infections related to dialysis treatments. Although data on fewer infection sites will be collected under the new system, surveillance will not be limited to the ICU and HRN only. Facilities may also choose to collect and report device-associated infection data for specialty care units, other wards, long-term care facilities, and home therapy. This will provide further flexibility in selecting the event and population under surveillance so that facilities may better tailor surveillance activities to their particular needs. Procedure-Associated Module. Data will be collected on inand outpatients undergoing NHSN-defined operative procedures. Under NHSN, seven more categories of procedure are covered than under NNIS, and whereas in the NNIS system information only on surgical site infections is collected, under the NHSN information on other surgical complications will also be collected. Further, the data collection protocols being designed for the NHSN will allow for more robust information on infections in surgical patients, including the ability to link bloodstream infections, pneumonia, and urinary tract infections occurring after an operative procedure to the procedure and the ability to monitor— by type of operation— procedure-associated pneumonia regardless of whether a ventilator is used. Medication-Associated Module. Antimicrobial resistance and antibiotic prescription monitoring will remain essentially unchanged in the transition from current surveillance activities to the NHSN.

Food and Drug Administration (FDA)

The task of the Food and Drug Administration (FDA) is to protect the public against food, drug, and medical device and product hazards and to ensure drug potency and effectiveness. Thus, the FDA regulates prescription drugs and over-the-counter medications, biological products, and human blood and its derivatives. The focus is on the assurance of the efficacy and safety of a product before marketing and on the assurance of continuing quality after approval. Medical devices are regulated in a similar manner. Radiological equipment is also regulated, the goals being to control radiation exposure to the public as well as to ensure efficacy. The regulatory programs of the FDA, especially those focusing on the efficacy and safety of drugs and medical devices, are sometimes controversial. Industry spokespeople maintain that the entry of useful drugs to the market is at times unnecessarily delayed by a lengthy and expensive approval process. Supporters of that process recall, for example, the thalidomide disaster. Nevertheless, in the mid-1990s, the FDA did manage to introduce internal reforms, significantly speeding up the drug review process (MacPherson, 1996). Even so, there has been continued controversy over the FDA regulatory process since that time. For example, in 2005, Senators Samuel Brownback (R-KS) and James Inhofe (R-OK) introduced the Access, Compassion, Care, and Ethics for Seriously Ill Patients Act (S. 1956), which would make it easier for seriously ill patients to receive drugs that are not yet fully approved (GovTrack.US, 2006). In 2005, Senators Charles Grassley (D-IO) and Christopher Dodd (D-CT) introduced the FDA Safety Act of 2005 (S. 930), which established the Center for Post market Drug Evaluation and Research to address the problems of adverse drug effects after a drug has gone to market (Library of Congress, 2006). Neither of these bills passed. In October 2011, Representative Michael Rogers (R-MI) introduced R. 3214: FDA Mission Reform Act of 2011, which proposes revisions to the FDA mission that address issues of regulation. For example, the bill proposes that the following language be included in the FDA mission statement: Ensures that regulations are accessible, consistent, transparent, written in plain language, and easy to understand Measures, and seeks to improve, the actual results of regulatory requirements Incorporates a patient-focused benefit-risk framework that accounts for varying degrees of risk tolerance, including for people living with a life-impacting chronic disease or disability (GovTrack.US, 2011) The Rogers bill, as of this writing of the book, was in the early stages of consideration.

DATA ANALYSIS AND FEEDBACK

The web-based system and central data repository being designed for the NSHN will allow participants to share data in a timely manner between users and public health agencies as well as among users (e.g., a multihospital system). The system will include data analysis wizards and statistical calculators, which will allow facilities (or groups of facilities) to generate custom reports, line lists, tables, graphs, and control charts easily. The ready availability of customizable internal and comparative analysis of infection rates is designed to facilitate the ability of health care providers to engage in continuous performance improvement. The system will also include a repository of prevention tools, lessons learned, and best practices. It is also designed to provide automatic feedback, including alerts for selected adverse events or near misses, identifying sentinel events that require an immediate response and need for root cause analysis, and identifying unusual events that might signal a preventable threat to patient safety.

National Institutes of Health (NIH)

The world's leading medical research center and the focal point for medical research in the United States. A division of the USDHHS; involved in research on disease. Mission: To seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce the burdens of illness and disability.

PUBLIC/PRIVATE PARTNERSHIPS AND PRIVATE INITATIVES

There are also a number of private initiative or private- public partnerships providing health care performance information to consumers and purchasers. Both the consumers and the purchasers of hospital services, such as insurance companies and the Medicare program, have a vital interest in the quality of those services. However, until fairly recently, consumers and purchasers had very limited ability to evaluate the quality of a hospital's performance in any aspect of care. Now, two organizations— the National Quality Forum (NQF) and the Leapfrog Group— are attempting to rectify this problem by developing standard measures of hospital quality and disseminating information about hospital performance to purchasers and consumers. The effectiveness of providing consumers and payers with information about health care quality is controversial and untested, as yet. National Quality Forum. The NQF is a nonprofit organization created to improve the quality of American health care by building consensus on national priorities and goals for performance improvement, endorsing national consensus standards for measuring and publicly reporting on performance, and promoting the attainment of national goals through education and outreach programs (National Quality Forum, 2012). Established in 1999 as a partnership between public and private stakeholders, the NQF aims to promote health care quality improvement by developing the intellectual framework for nationally standardized performance measures and quality data reporting so that individual hospitals and health systems can be compared. The NQF encourages the use of standardized measures by consumers and stakeholders within the health care system. However, it should be noted that the NQF has no authority to implement its standards, although payers of hospital services, such as insurance companies and the Medicare program can demand compliance with their standards. The NQF enjoys broad participation from health care consumer advocacy groups, public and private purchasers, health care professionals, employers, provider organizations, health plans, accrediting bodies, organized labor, and organizations involved in health care research and quality improvement. The organization is governed by a 27-member board of directors representing consumers, purchasers, providers, insurers, health services experts, and representatives from the CMS and the AHRQ. Currently, there are more than 200 member organizations active in the NQF. The NQF seeks not only to promote new guidelines, standards, and quality measures to rectify serious and pervasive quality deficiencies, but also to reconcile the redundant and often incompatible guidelines, standards, and reporting measures offered by various organizations and agencies dedicated to health care quality improvement. The NQF consensus process was developed pursuant to and in accordance with the National Technology Transfer Act of 1995 (U.S. Office of Management and Budget Circular A-119). This means that NQF endorsement of hospital performance measures and standards confers on them the special legal status of voluntary consensus standards . This status makes NQF-endorsed recommendations more easily adopted for use by Medicare, Medicaid, and other federally funded health care programs; that is, federal health care programs can require hospitals to adopt NQF recommendations in order to qualify for federal insurance programs. The NQF has issued reports endorsing a set of quality measures and endorsing patient safety practices. The measures are designed to provide consumers, providers, purchasers, and quality-improvement professionals the tools to evaluate and compare the quality of care in hospitals across the nation using a standard set of measures. The goal is to make data on these performance measures publicly available, and thus, enable performance-based decisions about hospital selection, create incentives for hospital performance improvement, enhance value-based purchasing, and generally stimulate the improvement of health care. The Leapfrog Group. The Leapfrog Group (2012) is a member-supported program aimed at mobilizing employer purchasing power to alert America's health industry that big leaps in health care safety, quality, and customer value will be recognized and rewarded. It was established in 2000 to: reward hospitals for advances in patient safety and quality and to educate employees, retirees, and families about the importance of hospitals' efforts in this area. Leapfrog purchasers provide health benefits to more than 34 million Americans and spend billions on healthcare annually. (Leapfrog Group, 2012, p. 1) Leapfrog was founded by the Business Roundtable, and its funding comes from its members. Leapfrog aims to give consumers information on hospital quality so that they are able to make more informed hospital choices and to mobilize employer health care purchasing power to improve patient safety. Focusing on quality of care issues relevant to urban area hospitals, the group works with medical quality-improvement experts to identify problems and propose solutions believed to improve hospital patient care. The Leapfrog Group's strategy is to recommend a set of safety practices, and then survey hospitals regarding the practice areas targeted. For each recommended practice, the hospital is rated on the following scale: fully implemented recommended practice, good progress in implementation, good early stage in implementation, willing to report but does not meet criteria for good early stage, and did not disclose. Leapfrog collects and makes publicly available comparative hospital ratings based on implementation of the recommended practices. This information is available through the HealthGrades website and through the Leapfrog Group website (www.leapfroggroup.org/cp). The Leapfrog Group encourages health care purchasers to provide incentives to hospitals that implement and report on the recommended practices. Incentives, such as increased patient volume, price variation based on performance, and public recognition are expected to encourage hospitals to adopt Leapfrog's recommendations. The Leapfrog Group further encourages corporate purchasers who utilize health plans as intermediaries to hold the health plans accountable for ensuring application of Leapfrog standards. The Leapfrog Group Safe Practices Score was based initially on the NQF's Safe Practices for Better Healthcare: A Consensus Report. Since that initial report, Leapfrog has utilized NQF updated reports to keep current. The most recent version of the report endorsed 34 practices that should be universally used in applicable clinical care settings to reduce the risk of harm to patients. There are practices aimed at: leadership and teamwork; preventing illness and infections; creating and sustaining a culture of safety; matching care needs to service capability; improving information transfer and communication; improving medication management, health care-associated infections, and specific care processes. Included in the 34 practices are two of the original three Leapfrog Leaps: computerized physician order entry and ICU physician staffing. After completion of the Leapfrog hospital survey, each hospital's relative ranking, compared with other hospitals, is displayed on the Leapfrog website, along with their results for the initial three Leaps and other measurement areas. In the 2011 Hospital Survey, Leapfrog scored hospitals' progress on 17 of the 34 NQF Safe Practice areas for a total of 737 points. Each practice area was assigned an individual weight, which was factored into the overall score. Hospitals were then ranked by quartiles. Institute for Healthcare Improvement. A number of private organizations provide expertise and leadership to hospitals that voluntarily aim to improve their quality of health care. Foremost among these organizations is the IHI. The IHI is a not-for-profit organization with a mission to improve health by focusing on a set of goals adapted from the Institute of Medicine's six improvement aims for the health care system: safety, effectiveness, patient centeredness, timeliness, efficiency, and equity (IHI, 2012). IHI attempts to bring change by identifying gaps; helping the public to understand and demand the improvement that is needed and possible; spreading improvement knowledge across the globe; and providing methods, tools, and other supports, largely through partnerships, for thousands of health care organizations to turn knowledge into improved results. IHI initiates and supports innovation efforts, so as to discover, cultivate, and demonstrate the feasibility of new, more capable designs. In terms of health care quality improvement, the IHI orientation is the Deming model of continuous quality improvement. The IHI focus is on innovation, research and development, and the creation of new solutions to old problems. In recent years, their research has been directed at transforming entire systems through redesign of all major care processes. This work was ultimately manifested in the 100,000 Lives Campaign and 5 Million Lives Campaign, in which IHI spread best practice changes to thousands of hospitals through the United States, and created a national network for improvement focused on reducing needless deaths and preventing harm from care.

Physician Sub types

There are five functional categories of physician staff in teaching hospital clinics. First, it was formerly very common for the hospital's voluntary (read private) attending medical staff to draw clinic duty as part of repaying the hospital for granting admitting privileges for their private patients at no cost to themselves. This is still the case in some institutions. Second, by the 1980s, many medical schools had become increasingly dependent for their financial support on taking a share of the income physicians earned in the clinics. The money was received primarily from third-party payers. Today, many clinics in medical school-owned teaching hospitals are staffed by medical school faculty whose work there generates both some of their own income and money for the school's general fund. The management system for dividing this income between the physicians and the institution providing the space and supporting staff is usually referred to as the clinical practice plan . Third, to carry out teaching, supervisory, and research functions, a teaching hospital may assign full-time salaried inpatient physicians, usually junior staff, to the clinics. Fourth, house staff (physicians in postmedical school, graduate specialty training, including interns, residents, and fellows) usually draw significant clinic duty from time to time throughout the course of their training. Fifth, for clinics with many patient visits, hospitals may hire outside physicians exclusively to work in them on a sessional or part-time salaried basis. All of these arrangements, in the context of the fragmented, subspecialty-focused organization of most teaching hospital clinics, create serious problems for the future development of primary care and primary care physicians. As one of the nation's experts on the subject, Fitzhugh Mullan, put it in terms that are still true today (Landy, 2001): "Medical education in the U.S. marginalizes primary care, and the current medical reimbursement system, which gives much higher compensation to specialists than to generalists, encourages medical institutions to skew treatment in favor of atomized high-tech interventions."Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail.action?docID=4558160.Created from stclaircc-ebooks on 2021-03-01 16:58:24.

Other Health Care Professionals and Occupations

There are many other categories of health worker. In mental health centers, for example, the staff includes psychologists, psychiatric social workers, nurses, and other support staff, in addition to psychiatrists. Community outreach workers are a new type of health care worker trained in recent years by certain ambulatory care programs, both general and mental. Other personnel in public health clinics include health educators, nutritionists and dietitians, and sexually transmitted disease investigators. Besides the personnel staffing the clinics, public health agencies employ sanitarians, statisticians, community health educators with specialized skills, and family planning counselors.

Organization of the U.S. Health Care System

There is not a single national structure for paying for or operating the health care system. The federal government plays an important role, but the states do, too. There is no single-payer system. Rather, the system is a mix of private and public organizations providing, paying, and to varying extents setting policy for health care at every level of the system. In the United States, each of the three levels of government— federal, state, and local— provides leadership and governance directly and indirectly through the regulation of the delivery of health services, their suppliers, and payers with the opportunity to drive market shifts through the operation of their own health services delivery and payer programs. The principal health agency of the U.S. federal government is the Department of Health and Human Services, headed by a cabinet-level secretary. The agency is responsible for the federal Social Security program, the federal role in the state-run public assistance programs, and the main federal programs in biomedical research, regulation, financing, and public health. Many of the department's responsibilities are met by allocation of money and delegation of authority to the many other public and private entities throughout the nation that are concerned with health matters. In each of the 50 states, there is a major health agency that is part of state government. As at the federal level, in some states the agency is combined with agencies for social welfare or other functions. The administrative configuration and scope of functions of the state health care agencies are highly variable. The heads of these agencies are ordinarily appointed by the state's governor. Administratively, they are responsible entirely to the governor and not at all to the Department of Health and Human Services. Only insofar as certain standards must be met as a condition for receipt of certain federal monies or in times of declared national emergency must the states accept national direction. Finally, a variety of health-related functions are carried out by nonhealth care governmental agencies. For example, at the federal level, the Department of Labor administers the Occupational Safety and Health Administration, and the Department of Agriculture sets national nutrition standards in cooperation with the Department of Health and Human Services. At all three levels of government, environmental protection services are often provided by an independent agency, for example, the Environmental Protection Agency at the federal level. An important category of the nonprofit sector is the health professional organizations, for example, the American Medical Association (AMA), the American Nurses Association (ANA), the American Public Health Association (APHA), the American Hospital Association (AHA), the Association of American Medical Colleges (AAMC), and the American Medical Athletic Association (AMAA). In this nation of organizations.

Categories of Nursing Education

There were about 2.6 million active RNs in the United States in 2013, up from 2.2 million in 2001 (NCHS, 2015b, Table 96). In addition, there were 113,000 nurse practitioners, 35,000 nurse anesthetists, and 5,460 nurse midwives in 2013, who would formerly have been counted in the active RN category, but who were given their own categories starting in 2010. In 2010, close to 1.3 million of RNs had associate degrees or hospital-based nursing school diplomas, about 731,000 had baccalaureate degrees, and almost 235,000 had graduate degrees. The RN/population ratio was about 860 per 100,000 in 2010. There are three major groups of nurses: RNs (including nurse midwives, nurse pracp0485 titioners, and nurse anesthetists), licensed practical nurses (LPNs), and nurses' aides. RNs have the highest level of education, the most responsibility under the states' nurse practice acts, and the most authority. Generally, LPNs and aides function under the supervision of an RN. "Registration" in nursing was originally a voluntary function of the nursing profession. It now means licensure by the states, at a significantly higher level of responsibility and authority than that accorded to the "licensed practical" nurse. To be an RN, one must have a high school diploma and a diploma from a hospital-based programor a bachelor of science in nursing (BSN) degree from a college or university, or, since 1952, an associate degree in nursing (ADN) from a 2-year college program. An increasingly prevalent accelerated nursing program enables those with degrees in other fields to change to a nursing career. There are also traditional master's and doctoral programs for RNs. The master's degree in nursing (MSN) is the preferred preparation for nursing leaders and advanced practice registered nurse (APRN) preparation is preferred for positions with prescriptive and diagnostic authority. These programs are designed and expected to advance the professional practice of nursing, meet expected workforce shortages, as well as provide better employment opportunities for individuals.

THE JOINT COMMISSION AND OTHER HEALTH CARE ACCREDITING ORGANIZATIONS

Though they are private entities, the accrediting organizations have a great deal of direct and indirect influence on quality assurance and improvement in health care. This is particularly true because of the relationship between the CMS certification process and accreditation by a CMS-approved accrediting organization: In order for a healthcare organization to participate in and receive payment from the Medicare or Medicaid programs, it must be certified as complying with the Conditions of Participation (CoP), or standards, set forth in federal regulations. This certification is based on a survey conducted by a state agency on behalf of the Centers for Medicare & Medicaid Services (CMS). However, if a national accrediting organization, such as The Joint Commission, has and enforces standards that meet the federal Conditions of Participation, CMS may grant the accrediting organization "deeming" authority and "deem" each accredited health care organization as meeting the Medicare and Medicaid certification requirements. The healthcare organization would have "deemed status" and would not be subject to the Medicare survey and certification process. (American Society for Healthcare Engineering [ASHE], 2012, p. 1) The CoPs and Conditions for Coverage (CfCs) set by CMS are standards that CMS considers essential for improving quality and protecting the health and safety of Medicare and Medicaid beneficiaries. Through its approval process, CMS tries to ensure that the standards of approved accrediting organizations meet or exceed the Medicare standards set forth in the CoPs and the CfCs (CMS, 2012). The Joint Commission (2012) is the oldest and largest health care accrediting organization in the country, accrediting nearly 19,000 health care organizations in the United States, including general, psychiatric, children's, and rehabilitation hospitals; critical access hospitals; home care organizations; nursing homes and other long-term care facilities; behavioral health care organizations; ambulatory care providers; and independent or freestanding clinical laboratories. The Joint Commission aims to provide standards for high-quality care that will ensure both patient and staff safety. Accreditation is designed to ensure quality care, maintain infection control, and help reduce the occurrence of medical errors. The performance measurement tools used by The Joint Commission have developed over the years. For example, in 1986, The Joint Commission (then JCAHO) developed the Indicator Measurement System (IMS). It had six sets of performance measures, for perioperative care, obstetrical care, trauma care, oncology care, infection control, and medication use. This system was not implemented, but it set the stage for the current ORYX initiative, which is based on multiple measurement systems. As described by The Joint Commission (2012, p. 1), the ORYX system Integrates outcomes and other performance measurement data into the accreditation process. ORYX measurement requirements are intended to support Joint Commission accredited organizations in their quality improvement efforts. Performance measures are essential to the credibility of any modern evaluation activity for health care organizations. In 2010, The Joint Commission categorized its performance measures into accountability and non-accountability measures. This approach places more emphasis on an organization's performance on accountability measures— quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement: research, proximity, accuracy and adverse effects. Non-accountability measures (for example, providing smoking cessation advice) are more suitable for secondary uses, such as exploration or learning within individual health care organizations, and are good advice in terms of appropriate patient care. Going forward, The Joint Commission will only adopt accountability measures for its ORYX program. The principal objective of measurement activities, including ORYX, is to create the technical infrastructures within health care organizations and also The Joint Commission to support performance measurement and improvement in the health care system (The Joint Commission, 2012). Other CMS-approved, but much smaller, accrediting bodies for hospitals are the American Osteopathic Association's Healthcare Facilities Accreditation Program and DNV Healthcare, which were approved in 2008. The Accreditation Association for Ambulatory Health Care, the American Association for Accreditation of Ambulatory Surgery Facilities, and the Accreditation Commission for Health Care are CMS-approved for nonhospital health care settings, including ambulatory surgery centers and hospices (CMS, 2012).

National Institutes of Health (NIH)

Through its multiple institutes, such as the National Cancer Institute and the National Heart, Lung, and Blood Institute, the National Institutes of Health (NIH) is responsible for supporting and carrying out biomedical research. Its primary mission focuses on basic biomedical research at the organ-system, tissue, cellular, and subcellular levels. NIH has its own (intramural) research program on its campus in Bethesda, Maryland, and provides funds for research at many other institutions around the country through (extramural) grants and contracts. NIH also fosters research by supporting training, resource development, and construction.

APPENDIX B: TIMELINE OF EVENTS IN DEVELOPMENT OF THE U.S. HEALTH CARE SYSTEM, 1763-2015

Timeline of Events in Development of the U.S. Health Care System, 1763- 2015 1763: Physicians petition to allow doctors to found societies with licensing powers. 1798: Edward Jenner publishes his work on developing a vaccine against smallpox. 1813: U.S. Vaccine Agency is established and the U.S. Post Office is required to carry smallpox vaccine material for free. 1847: The American Medical Association is founded. 1854: President Franklin Pierce vetoed a national mental health bill on the basis that it would be unconstitutional to regard health as anything but a private matter in which government should not become involved. 1861- 1865: U.S. Civil War mobilizes a "support army" to care for the wounded, advancing the practice of surgery, nursing, and emergency medicine while establishing new legitimacy for physicians. 1877: Louis Pasteur proposed The Germ Theory of Disease. 1895: X-rays are discovered and almost immediately put into use for medical research and diagnostics. 1900: About six to nine women died per 100 live births and the infant mortality rate averaged around 100 while reaching up to 300 in some U.S. cities. 1900: Bertillon or International List of Causes of Death is adopted (predecessor of International Classification of Diseases [ICD]). 1902: The Biologics Control Act is passed to ensure purity and safety of serums, vaccines, and similar products used to prevent or treat diseases in humans. 1906: Pure Food and Drug Act is passed prohibiting interstate commerce in adulterated and misbranded food and drugs, establishing the forerunner of the Food and Drug Administration. 1910: Flexner Report facilitates new standards for medical schools essentially endorsing AMA standards and practices as standards for medicine. 1920: AMA opposed compulsory health insurance through a resolution by house of delegates. 1929: Blue Cross Plans are established to provide "pre-paid" hospital care. 1930: Blue Shield Plans begin providing reimbursement for physician services. 1930: NIH is established for purpose of discovering the causes, prevention, and cure of disease. 1935: Social Security Act is approved. It does not include compulsory health insurance as a result of AMA influence. 1938: The Federal Food, Drug, and Cosmetic (FDC) Act of 1938 establishes the FDA to oversee the safety of food, drugs, and cosmetics. 1943: Penicillin is mass produced for the first time. 1940- 1944: U.S. businesses begin to offer health benefits as they compete for workers, giving rise to the employer-based systems in place today. 1948: AMA launches a campaign against President Truman's plan for national health insurance; the plan is subsequently defeated. 1951: Durham- Humphrey Amendment establishes a system prohibiting sales of many drugs except under prescription from a physician. 1955: Health insurance coverage grows to nearly 70% from 10% in 1940. 1962: Kefauver- Harris Drug Amendments require drug manufacturers to prove scientifically that a medication is not only safe, but effective prior to marketing. 1965: Medicaid and Medicare are created to ensure access to health care for the poor and elderly. 1973: The Health Maintenance Organization Act is signed into law to encourage the development of competition in the health care market. 1983: Medicare Prospective Payment System replaces the generally "cost-plus" reimbursement model that threatened Medicare's solvency. 1986: Emergency Medical Treatment and Labor Act requires hospitals to provide appropriate medical screening and stabilizing treatment to anyone who presents for care. 1989: New Medicare physician fee schedule replaces previous "customary and usual" rate schedules while Stark Law limits self-referrals. 1996: Health Insurance Portability and Accountability Act establishes that the data within the medical record belongs to the patient, provides for continuity or "portability" of coverage during changes in insurance, and gives mental health the same status as physical health. 2000: U.S. infant mortality rate is 6.89 per 1,000 live births, a nearly 95% decrease since 1900. 2001: The Human Genome Project consortium publishes a 90% complete sequence of all 3 billion base pairs in the human genome, understood to be the blueprint for life. 2006: Massachusetts implements laws to provide health care coverage for nearly all state residents. 2010: Passage of the Patient Protection and Affordable Care Act, which aims to (a) increase access; (b) increase quality; and (c) decrease cost of health care through new regulations and taxes on physicians, hospitals, insurers/payors, drug and medical device companies, and establishes national and state-based health insurance marketplaces modeled after Massachusetts' program. 2015: International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is implemented (approximately 21 years after WHO developed ICD-10 and 18 years after the National Center for Health Statistics began the first round of testing). 2015: The Medicare Access and Children's Health Insurance Program Reauthorization Act will shift physicians to alternative payment models designed to encourage quality and efficiency.

Maintaining a Network of Providers

To maintain this conversion, the third-party payer maintains a network of providers with which it has negotiated contracts. These contracts detail which payment models will be used and what rates will be used, as well as other details common to commercial contracts.

Access to treatment psych modules

Up to one-in-four primary care patients suffer from depression; yet, primary care doctors identify less than one-third (31 percent) of these patients. Among the 8.9 million adults with any mental illness and a substance use disorder, 44 percent received substance use treatment or mental health treatment in the past year, 13.5 percent received both mental health treatment and substance use treatment and 37.6 percent did not receive any treatment. Four percent of young adults reported forgoing mental health care in the past year, despite self-reported mental health needs. People with psychotic disorders and bipolar disorder are 45 percent and 26 percent less likely, respectively, to have a primary care doctor than those without mental disorders.

QUALITY OF HEALTH CARE

Using the model originally developed by Avedis Donabedian, health care quality is assessed in terms of structure, process, and outcomes (Donabedian, 1980- 1985). "Structure . . . is meant to designate the conditions under which care is provided" (Donabedian, 2003, p. 46). It includes material resources, such as facilities and equipment; human resources, such as number and qualities of professional and support personnel providing health care; and organizational characteristics, such as (for individual facilities such as hospitals) nonprofit status, academic affiliation, and governing structure. Examples of structure-oriented questions are: What is the nurse-to-patient ratio on a hospital floor? What is the age of the facility? What proportion of a hospital's patients do not have insurance, are receiving Medicaid, or are covered by Medicare? Are the physicians in a practice salaried employees or paid on a fee-for-service basis? Process "is taken to mean the activities that constitute health care— including diagnosis, treatment, rehabilitation, prevention, and patient education— usually carried out by professional personnel, but also including other contributions to care, particularly by patients and their families" (Donabedian, 2003, p. 46). For example, a study of health care process might ask the following questions: Is infection control policy followed by the hospital staff? How long does it take for the primary care physician to receive the test results needed for diagnosis? How does the treating physician transmit information about a drug's side effects to the patient? What is the waiting time in the emergency room? How much time does a physician spend with a patient, on average, for an annual physical? What is the standard practice among the physician staff for treating a particular health condition, such as acute myocardial infarction or stroke? Structure and process influence the outcomes, or effectiveness, of health care. For example, each of the structure and process-oriented issues just mentioned may lead to poor health care outcomes, but they are not outcomes in themselves. Outcomes "are taken to mean changes (desirable or undesirable) in the health of individuals and populations that can be attributed to health care" (Donabedian, 2003, p. 46). Generally speaking, there are two types of outcomes used to assess the quality of health care systems: (a) the outcomes of persons who have received care, that is, patients; and (b) population health outcomes, that is, the outcomes of both people who have and people who have not received health care. We begin with population health outcomes and then consider the health outcomes of patients.

Value

Value-based compensation is the payment model in which the performing organization is rewarded for the value delivered. Value-based systems are most often used when the value is easy to measure and indisputable. For example, personal injury lawyers often offer their services purely for a contingency fee because the value of the lawsuit proceeds is easy to measure. One of the assumptions of market theory is that the buyer, in this case, the patient, has a sense of the value of what he or she is buying. As Arrow pointed out in 1963, the uncertainties surrounding medicine make it difficult for providers to know the real value of what they are providing and even more difficult for the patient, who is almost certainly at an information disadvantage relative to the provider. On the other hand, if patients started paying for care according to how much it was worth to them economically, the system would tend toward valuing the lives of wealthier people more highly, which most people would find unethical. Finally, in an emergency situation, a patient may not be able to value care until after the care is provided. Nonetheless, the system's need to move beyond fee-for-service has motivated solutions that, if not ideal, appear to motivate providers to provide better care than those common under fee-for-service arrangements. In order to avoid the cost and complexity of trying to determine quality on a case-by-case basis, most are based on statistically significant achievements on process and outcomes measures. As discussed in more depth in later chapters, these appear to be driving significant improvements in outcomes on health care delivery problems that were previously considered intractable. Although the use of financial incentives as a strategy to drive improvements in care dates back several decades among private payers and Medicaid programs, with limited experimentation occurring in the early 1990s and somewhat wider use in the late 1990s and early 2000s, the Affordable Care Act moved Medicare's Value Based Purchasing Program from demonstration to mandate (www.rand.org/content/dam/rand/pubs/ research_reports/RR300/RR306/RAND_RR306.pdf). A hospital quality data reporting infrastructure originally established with the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 now affects the payments for inpatient stays in over 3,500 hospitals across the country (www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/hospital-value-based-purchasing/index.html). Similar programs have been or are being established for nealy all aspects of the health care system.

SUMMARY

We have discussed health care system performance from the perspective of three recognized criteria: (a) quality of health care, (b) equity of health care, and (c) efficiency of health care. Of the three, we have spent the most time on the quality of health care, mainly because over the past 20 years an increasingly large effort has developed to measure and improve quality at the microlevel. Evaluations of clinical effectiveness and patient safety are based on empirical studies that provide evidence about best practices and are the foundation of clinical practice guidelines. These studies have been well funded, and the practice guidelines that have resulted are increasingly used to evaluate the performance of health care providers— individual providers and organizations. Public as well as private organizations are involved in this effort. Equity in access to and quality of health care, although not a major focus of this chapter, is a major concern to policy makers in the United States. Our history is replete with attempts to make our system equitable by extending health care coverage to all Americans. This history is detailed in the final chapter, but no attempts have been completely successful. The efficiency of the health care system is another area that, although important, has received less attention in this chapter. However, many of the QIs are driven by an equal interest: making our system more efficient. Finally, we have briefly touched on the importance of data for evaluating health care performance. In the area of health information, there is tremendous activity, partially driven by improvements in the technological capability to computerize information. The EMR will be the standard very shortly for all health care providers— individual and institutional—and the digitizing of this information and other information about patients will follow. Again, this development will have a significant impact on the way care is delivered and how easily it is able to be evaluated. Thus, health information systems, too, will affect the work and future of all health professionals.

Third-Party Payers Insurance (Risk Management)

Who should pay for health care? As important as how we pay for health care is who controls the payments. Although ultimately all costs of health care are borne by the people, how the money gets from the people to the providers of goods (antibiotics, vitamins, wheelchairs, etc.) and services (physicians, hospitals, chiropractors) shapes the system. A system where people purchase directly from the providers, just as they purchase cars and hire mechanics, will be very different from one in which the people give their money to the government, which then maintains a health care system much like all governments maintain a military. Although most people do not need very much health care in a given year, any significant health care incident is likely to be very expensive. Severe illness can easily cost tens of thousands of dollars, and heroic measures (e.g., trauma and organ transplants) can easily cost in the hundreds of thousands of dollars. Some rare conditions can even cost into the millions of dollars to treat (Thomas, 2006; Zhang, 2006). A health care condition requiring $500,000 in treatment would exceed the lifetime income of most people and would be financially devastating for all but a small percent of the population. As noted earlier, whereas a significant number of people retain their health expenditure rank from year to year, a sizeable number do not. Therefore, most people desire some sort of insurance to protect themselves against wild swings in health care costs. As Glied (2001) pointed out, people do not buy health insurance to insure their health, but rather to insure their ability to pay for (and obtain) health care in the event that their health status changes. Historically, health insurance was intended to cover major medical events.

SQ 1) How has government spending on health care changed since 1960 and what are the reasons for this change?

With Medicare and Medicaid have been increased in the government's role in healthcare and helping provide insurance for those who have less. There has been less people who can pay out of pocket. Medicare was enacted as part of an act in 1965. The Medicare act was used as part of an act for elders over the age of 65.

Administration for Community Living

With approximately 200 full-time employees, the Administration for Community Living (ACL) is focused on ensuring that older adults and people with disabilities are able to have the option to live at home and fully participate in their communities. Created in April 2012, ACL brought together three previously separate entities within DHHS: the Administration on Aging, the Office on Disability, and the Administration on Intellectual and Developmental Disabilities (AIDD).

OBAMA HEALTH PLAN FROM THE CONSUMER PERSPECTIVE

With enactment of the Patient Protection and Affordable Care Act (ACA) of 2010 under President Obama, we have seen comprehensive reform in the U.S. health care system for the first time. Yet, consistent with the American context discussed in Chapter 7, the overhaul of the health care system maintains the mixed public and private system. All previous private-sector participants in health care delivery are present, even though governmental involvement has been expanded through mandates on individuals, employers, health insurance companies, health care providers, including physicians, hospitals, and long-term care facilities, as well as pharmaceutical companies. An example of the reach of the bill's mandates is the overall approach to expanding access to health care coverage: Require most U.S. citizens and legal residents to have health insurance. Create state-based American Health Benefit Exchanges through which individuals can purchase coverage, with premium and cost sharing credits available to individuals/families with income between 133- 400% of the federal poverty level (the poverty level is $18,310 for a family of three in 2009) and create separate Exchanges through which small businesses can purchase coverage. Require employers to pay penalties for employees who receive tax credits for health insurance through an Exchange, with exceptions for small employers. Impose new regulations on health plans in the Exchanges and in the individual and small group markets. Expand Medicaid to 133% of the federal poverty level. (Kaiser Family Foundation, 2011, p. 1) In addition, there has been an expansion of the public programs— Medicaid and SCHIP— under the ACA, as well as creation of state-based health insurance exchanges— American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges— that will be "administered by a government agency or nonprofit organization through which individuals and small businesses with up to 100 employees can purchase qualified coverage" (Kaiser Family Foundation, 2011). Therefore, we can say that today public-sector involvement in the health care delivery system is substantial, although the private sector is as well.

Price and Provider Expertise

With the most extensive databases of patient visits, especially over time, third-party payers have the benefit of expertise. The databases of third-party payers are a wellspring of information for longitudinal studies and better understanding of treatment options. Third-party payers deal with an array of providers daily. They know the going rate for a wide variety of procedures and consultations across geographic regions and quality tiers. They can conduct quantitative quality studies more easily than any other organization. Therefore, it is third-party payers who have the best chance of predicting which providers will offer a good outcome.

Physicians Assistants

■ Approaching a patient of any age group in any setting to elicit a detailed and accu■ rate history, perform an appropriate physical examination, delineate problems, and record and present patient data ■ Analyzing health status data obtained via interview, examination, and laboratory diagnostic studies and delineating health care problems in c onsultation with the physician ■ ■ Formulating, implementing, and monitoring an individualized treatment or management plan for a patient in consultation with the physician ■ ■ Instructing and counseling patients regarding compliance with the prescribed therapeutic regimen, normal growth and development, family planning, emotional problems of daily living, and health maintenance ■ ■ Performing routine procedures essential to managing simple conditions produced by infection or trauma, assisting in the management of more complex illness and injury, and initiating evaluations and therapeutic procedures in response to life-threatening situations

Th People who provide Health Care

■ ■ 33.6% worked in hospitals ■ ■ 13.5% in nursing and other residential care facilities ■ ■ 15.9% in practitioner offices and clinics, including those of physicians, dentists, c hiropractors, optometrists, and other practitioners ■ ■ 15.6% in social assistance (U.S. Department of Labor, 2015, Table 18)

Structure

■ ■ Administration: including common corporate functions, such as finance and human resources ■ ■ Nursing: clinical departments such as inpatient nursing units ■ ■ Ancillary services: other clinical departments, such as cardiology and radiology, which may serve a mix of inpatients and outpatients ■ ■ Support services: facility services such as plant maintenance, housekeeping, and food service ■ ■ Outpatient services: typically ambulatory clinics and other outpatient-only departments Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central,

Primary Care Workforce

■ ■ Assessment of total patient needs before these are categorized by specialty ■ ■ Elaboration of a plan for meeting those needs in the order of their importance ■ ■ Determination of who shall meet the defined needs— physicians (generalist or spe■ cialist), nonphysician members of the health care team, or social agencies ■ Follow-up to see that needs are met ■ ■ Provision of such care in a continuous, coordinated, and comprehensive manner ■ ■ Attention at each step to the personal, social, and family dimensions of the patient's problem ■ ■ Provision of health maintenance and disease prevention at the same level of importance as the provision of cure and rehabilitation

PREVENTION AND MENTAL HEALTH

■ ■ Mental health, behavioral health, and physical health will be more tightly linked in diagnosis and treatment. ■ ■ There will be continuing interest in prevention in order to control health care costs. This trend also links primary care and public health, in order to foster prevention and to diagnose early. ■ ■ The health care systems will become more oriented toward promoting health in populations (population health).