Blendon RJ, Scoles K, DesRoches C, Young JT, Herrmann MJ, Schmidt JL, Kim M. 2001. Untreated ear infections, for example, can have permanent consequences of hearing loss or deafness. There is a significant . Furthermore, changes in the funding streams or reimbursement policies for any of these programs or increases in demand for free or subsidized care that inevitably occur in periods of economic downturn create crises for safety-net providers, including those operated by state and local governments (see the section Collaboration with Governmental Public Health Agencies later in this chapter for additional discussion). To support the system, the United States spends more per capita on health care than any other country ($4,637 in 2000) (Reinhardt et al., 2002). . Yet the public and many elected officials seem almost willfully ignorant of the magnitude, persistence, and implications of this problem. Only a small fraction of physicians offer e-mail interaction (13 percent, in a 2001 poll), a simple and convenient tool for efficient communication with their patients (Harris Interactive, 2001). These numbers are greater than the combined populations of Texas, California, and Connecticut. The committee also urges greater efforts on the part of the health care delivery system to meet its public health responsibilities and greater efforts on the part of governmental public health agencies to reach out to health care providers and purchasers and engage them more fully in the public health system. Policies promoting the portability and continuity of personal health information are essential. Better information technology can also support patients and family caregivers in crucial health decisions, strengthen both personal and population-based prevention efforts, and enhance participation in and coordination with public health activities. Governmental public health agencies also depend on astute clinicians to inform them of sentinel cases of recognized diseases that represent a special threat to the public's health and of unusual cases, sometimes without a confirmed diagnosis, that may represent a newly emerging infection, such as Legionnaires' disease or West Nile virus in North America. The cost to society is also high, with indirect costs from lost productivity for affected individuals and their caretakers estimated at $79 billion in 1990, the last year for which estimates are available (Rice and Miller, 1996). Bindman and colleagues (1995) similarly concluded that at the community level, there is a strong positive association between health care access and preventable hospitalization rates, suggesting that these rates can serve as an indication of access to care. It would be a costly mistake to create additional emergency and inpatient capacity before decompressing demand by improving access to primary care services. Additionally, Montefiore Medical Center partners with local high schools to develop health care professions education programs intended to create new career options and improve the likelihood inner-city youth will stay in school (Montefiore Medical Center, 2001). Findings from Coverage Matters. People turn to safety-net providers for a variety of reasons: some because they lack health insurance and others because there are no other providers in the area where they live or because language and cultural differences make them uncomfortable with mainstream care. Because the largest public programs are directed to the aged, disabled, and low-income populations, they cover a disproportionate share of the chronically ill and disabled. Henry J. Kaiser Family Foundation and As the committee has noted, health-related (mostly health care-related) spending in the United States amounted to $1.3 trillion in 2000, about 13.2 percent of the gross domestic product (Levit et al., 2002). 2001. For example, chronic conditions like asthma and diabetes often can be managed effectively on an outpatient basis, but if the conditions are poorly managed by patients or their health care providers, emergency or inpatient care may be necessary. U.S. Department of Housing and Urban Development. (2002); CMS (2002a); CMS (2002c). Health care delivery forms the most visible function of the health system, both to patients and the general public. The operational separation of public health and health care financing programs mirrors the cultural differences that characterize medicine and public health. For Americans to enjoy optimal healthas individuals and as a populationthey must have the benefit of high-quality health care services that are effectively coordinated within a strong public health system. Even when insured, limitations on coverage may still impede people's access to care. Reinhardt UE, Hussey PS, Anderson GF. In 1976, the U.S. Congress added the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program to the federal Medicaid program. Teutsch SM, editor; , Churchill RE, editor. Epidemiologic Catchment area prospective 1-year prevalence rates of disorders and services, Cross-national comparisons of health systems using OECD data, 1999, The economic burden of schizophrenia: conceptual and methodological issues, and cost estimates, Handbook of Mental Health Economics and Health Policy: Schizophrenia, Trends in job-based health insurance coverage, Substance Abuse: The Nation's Number One Health Problem. One out of five employer-sponsored plans does not cover childhood immunizations, and one out of four does not cover adolescent immunizations although these are among the most cost-effective preventive services. Kaiser Permanente Medical Group pioneered the model more than 50 years ago on the basis of early experiences providing health care programs for employees of Kaiser industrial companies (e.g., construction, shipyards, steel mills) in the late 1930s and 1940s.1. Insurance status is a powerful determinant of access to care: people without insurance generally have reduced access. Total of medical and surgical beds, ICU beds, and special care beds. Americans now live longer. 2001. a. AHCPR (Agency for Health Care Policy and Research). The most common conditions fall into the broad categories of schizophrenia, affective disorders (including major depression and bipolar or manic-depressive illness), and anxiety disorders (e.g., panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and phobia). (more). In some instances, physicians and laboratories may be unaware of the requirement to report the occurrence of a notifiable disease or may underestimate the importance of such a requirement. Adequate population health cannot be achieved without making comprehensive and affordable health care available to every person residing in the United States. Furthermore, nurses have available other professional opportunities, and women, who once formed the bulk of the nursing workforce, now have alternate career prospects. In the early 1990s, managed care became a common feature of the health care delivery system in the United States. Preventive Services Covered by Medicare. However, when fewer diagnostic tests are performed for self-limiting illnesses like diarrhea, there may be delays in recognizing a disease outbreak. Lasker and colleagues observed, [t]he dominant, highly respected medical sector focused on individual patients, emphasizing technologically sophisticated diagnosis and treatment and biological mechanisms of disease. IHS (2002a, 2002b). Crossing the Quality Chasm (IOM, 2001b) formulated the case that information technology is critical to the redesign of the health care system to achieve a substantial improvement in the quality of care. In a recent survey of public health agencies, primary care or direct medical care services were the least common services provided (NACCHO, 2001). . Ensure that services are cost- effective and meet established standards of quality. The four basic functional components of the US healthcare delivery system are as follows: Financing. e Kaiser Family Foundation and Unfortunately, the Medicare program was not designed with a focus on prevention, and the process for adding preventive services to the Medicare benefit package is complex and difficult. Solis JM, Marks G, Garcia M, Shelton D. 1990. Components of the U.S. health care system. 308 qualified specialists online. The American Hospital Association (AHA, 2001a) reports that from 1994 to 1999, the number of emergency departments in the nation decreased by 8.1 percent (see Table 53). The first sector of health care is primary care. RNs work in a variety of settings, ranging from governmental public health agency clinics to hospitals and nursing homes. Medicare's pilot project IdeaTelInformatics for Diabetes Education and Telemedicineoffers web-based home systems to rural and inner-city diabetics to support home monitoring, customized information, and secure links to providers and to the patients' own medical records (www.dmi.columbia.edu/ideatel/info.html). Inequities in health services among insured Americans: do working-age adults have less access to medical care than the elderly? Absent the availability of health insurance, the role of the safety-net provider is critically important. A child born today can expect to live more than 75 years, and advances in medicine have also extended the life spans of earlier generations. Medical screening. Children without health insurance may be compromised in ways that will diminish their health and productivity throughout their lives. The advent of managed care plans that seek services from the lowest-cost appropriate provider and changes in federal (Medicare) reimbursement policies that reduced subsidies for costs associated with AHCs' missions in education, research, and patient care have created considerable pressure on academic institutions to increase efficiency and control costs. One strategy to help lessen the negative impacts of changes in health care financing undertaken by some public health departments has been the development of formal relationships (e.g., negotiating and implementing memoranda of agreement) with local managed care organizations that provide Medicaid and, in some cases, safety-net services. Sentinel networks that specifically link groups of participating health care providers or health care delivery systems to a central data-receiving and -processing center have been particularly helpful in monitoring specific infections or designated classes of infections. According to a report of the Surgeon General, fewer than one in five Medicaid-covered children received a single dental visit in a recent year-long study period (DHHS, 2000b). Some of the motivation comes from the increasing pressure on nonprofit hospitals to justify their tax-exempt status through the provision of services that benefit the community, largely the provision of charity care; yet, many are seeing that investments in community health improvement are greater in value than the provision of medical care for preventable diseases (Barnett and Torres, 2001). Coverage of clinical preventive services has increased steadily over the past decade. The rapid development and widespread implementation of an extensive set of standards for technology and information exchange among providers, governmental public health agencies, and individuals are critical. Avoid fragmentation of health plans along socioeconomic lines. Using delivery system innovations to advance health care reform continues to be of widespread interest. Until recently, the Medicaid waiver program, administered by CMS on behalf of the Secretary of Health and Human Services, did not provide protection of reimbursement rates for clinics within the safety-net system. When individuals cannot access mainstream health care services, they often seek care from the so-called safety-net providers. AAMC (Association of American Medical Colleges). Other types of public health surveillance activities, such as registries for cancer cases and for childhood immunizations, also depend on reporting from the health care system. Services: Having a usual source of care is associated with adults receiving recommended screening and prevention . 1995. Because insurance status affects access to secure and continuous care, it also affects health, leading to an estimated 18,000 premature deaths annually (IOM, 2002a). Uninsured people are less likely to receive medical care and more likely to have poor health status. Heffler S, Smith S, Won G, Clemens MK, Keehan S, Zezza M. 2002. 1986. Evidence-based practice guidelines for depression endorse antidepressant medications and cognitive-behavioral or interpersonal psychotherapies (AHCPR, 1993; Department of Veterans Affairs, 1993; Schulberg et al., 1999). Substance Abuse and Mental Health Services Administration. A sophisticated health information infrastructure is also important to support public health monitoring and disease surveillance activities. Legnini MW, Anthony SE, Wicks EK, Mayer JA, Rybowski LS, Stepnick LS. Mental health parity: what are the gaps in coverage? Although the terrorist incidents in the fall of 2001 did not directly test the ability of hospitals to respond to a medical crisis, they drew particular attention to hospitals' limited surge capacitythe ability to absorb a large influx of severely injured patientsin their emergency departments and specialty units. Concerted efforts should be directed to improving this nation's capacity and ability to monitor the changing structure, capacity, and financial stability of the safety net to meet the health care needs of the uninsured and other vulnerable populations. DHHS (2002). For example, the California Public Employees' Retirement System, which is the nation's second largest public purchaser of employee health benefits, recently announced that health insurance premiums would increase by 25 percent (Connoly, 2002). The report found that aspects of the health care systemits organization, financing, and availability of servicesmay have adverse effects specifically for racial and ethnic minorities. The committee focused on the problem of insurance and access to care. 2002. However unlike most countries which provide readily access to these major . Adults without health insurance are far more likely to go without health care that they believe they need than are adults with health insurance of any kind (Lurie et al., 1984, 1986; Berk and Schur, 1998; Burstin et al., 1998; Baker et al., 2000; Kasper et al., 2000; Schoen and DesRoches, 2000). The exception is preventive services for children. To ensure healthy patients, you must have healthy health care systems. During the 1990s, the spread of managed care practices contributed to reductions in overall hospital admissions, in the length of hospital stays, and in emergency department visits. True Which type of hospital earns a profit from the services that are provided? Although Billings and colleagues focused on the preventable demands for hospital care among low-income and uninsured populations, Closing the Quality Chasm (IOM, 2001b) makes clear that the misuse of services also characterizes disease management among insured chronically ill patients. SOURCES: Findings from the National Sample Survey of Registered Nurses, Public health reporting flaws spell trouble: doctors complain about requirements that appear to lack follow-through, Primary Care: Balancing Health Needs, Services and Technology, The role of primary care in improving population health and equity in the distribution of health: an unappreciated phenomenon, Policy-relevant determinants of health: an international perspective, EPSDT: Early Periodic Screening Detection and Treatment: a snapshot of service utilization, Health insurance may be improvingbut not for individuals with mental illness, Mental health care utilization in prepaid and fee-for-service plans among depressed patients in the medical outcomes study, SAMHSA fact sheet: analysis of alcohol and drug abuse expenditures in 1997, Principles and Practices of Public Health Surveillance, Future directions for comprehensive public health surveillance and health information systems in the United States, Employer-sponsored health insurance: pressing problems, incremental changes, Linking affordable housing to community development, Building Higher Education Community Development Corporation Partnerships, National Preparedness: Ambulance Diversions Impede Access to Emergency Rooms, Budget of the United States Government. Some provide no personal health care services at all, whereas others provide some assortment of primary health care and safety-net services. Additionally, public funding supports directly delivered health care (through community health centers and other health centers qualified for Medicaid reimbursement) accessed by 11 percent of the nation's uninsured, who constitute 41 percent of patients at such health centers (Markus et al., 2002). Moreover, they are also primary loci for research and training. Committee on Medicine and Public Health. Ultimately, such systems should also allow the public to contribute and receive information to get the most complete database possible. Objective The WHO developed a manual outlining the preliminary organizational and health professionals' readiness to implement electronic medical records (EMR). OPM (Office of Personnel Management). 1. Many hospitals and health care systems have seen the value of going beyond the needs of the individuals who enter the health care system to engage in broader community health action, even within the constraints of the current environment. Introduction Health care delivery system is a network of integrated components designed to work together coherently,to provide healthcare to a population in various settings. Additionally, the system has continued to undergo continuous changes . These risk behaviors are estimated to account for more than half of all premature deaths; smoking alone contributes to one out of five deaths (McGinnis and Foege, 1993). One notion of an integrated delivery system was the concept of placing all the required levels of care within one integrated delivery system which will allow the purchaser and consumer of health care service to receive all the needed services within a seamless delivery system that would facilitate the needed access to the appropriate level of care at the appropriate . 2000. A number of major insurance plans have announced that they will begin to offer defined-contribution options.2 This may be attractive to employers, whose liability will be defined by a specific premium amount rather than by a specified set of benefits. What are the primary objectives of a health care delivery system? (Eds.). Recommended Content: Reserve Health Readiness Program (RHRP) | Health Care Administration & Operations The Reserve Health Readiness Program provides services to members of the National Guard or Reserve and to active duty service members enrolled in TRICARE Prime Remote, including medical readiness, dental readiness, and deployment services. Poor Mexican-American children ages 2 to 9 have the highest proportion of untreated decayed teeth (70.5 percent), followed by poor non-Hispanic African-American children (67.4 percent). Yet about half of all pregnancies and nearly a third of all births each year are unintended. 2002. The growing cost of health care has obvious implications for the nation's readiness to address the problems discussed in this chapter. The health care delivery system is the policy, organizations, and regulations that promote positive patient health with direct, and indirect strategies. Over a 2-week period, there was a 13 percent reduction in trauma admissions from car crashes due to a public awareness campaign and police initiative (AHA, 2002). What makes up the healthcare system? 1994. Of the 22.9 million children eligible for the EPSDT program in 1996, only 37 percent received a medical screen through the EPSDT program. Mental disorders are a major public health issue because they affect such a large proportion of the population, have implications for other health problems, and impose high costs, both financial and emotional, on affected individuals and their families. The IOM Committee on the Changing Market, Managed Care and the Future Viability of Safety Net Providers defined safety-net providers as [t]hose providers that organize and deliver a significant level of health care and other health-related services to uninsured, Medicaid, and other vulnerable patients (IOM, 2000a: 21). Nearly 3 out of every 10 Americans, more than 70 million people, lacked health insurance for at least a month over a 36-month period. Denver Health is the local (county and city) public health authority, as well as a managed care organization and hospital service. Cardiovascular disease and diabetes exemplify the problem. In other words, to deliver true evidence-based care, evidence-based management is necessary to support it. As a result of the nation's increased awareness of bioterrorist threats, there are concerns about the implications of copayments and other financial barriers to health care. Focuses on quality of care, not volume of services provided Aligns incentives across all parts of our system, with patients at the center, delivering high-value care and keeping costs reasonable Invests in new technologies and innovations to advance quality of care First, as noted earlier, AHCs are an important part of the safety-net system in most urban areas. Although more research is needed to examine the impact of minority health care professionals on the level of access and quality of care, for some minority patients, having a minority physician results in better communication, greater patient satisfaction with care, and greater use of preventive services (IOM, 2002b). Health care expenditures and mortality experience, Trends in health insurance coverage: a look at early 2001 data, Oral health: dental disease is a chronic problem among low-income populations, Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health Screening Services, Strategic objective: the health needs of an aging and diverse population, The causes of vulnerability: disentangling the effects of race, socioeconomic status and insurance coverage on health, Comparison of uninsured and privately insured hospital patients: condition on admission, resource use, and outcome. Although at the time the health system had been increasing its health care outreach programs, it realized it had to look at root causes. As the largest employer in Chester, the system organized Community Connections, a mosaic of health, economic, and social programs and services developed in partnership with 20 other organizations, a local university, and governmental agencies. Contrary to popular belief, recent immigrants accounted for a relatively small proportion of the uninsured (less than one in five). Some are based in the public sector; others operate in the private sector as either for-profit or not-for-profit entities. Young AS, Klap R, Sherbourne CD, Wells KB. Nearly 14 million people in the United States are not proficient in English. Support the use of interpretation services where community need exists. In 2000, 9 percent of physicians and 12.3 percent of RNs were from racial and ethnic minority groups (AAMC, 2000). A recent study of changes in the capacities and roles of local health departments as safety-net providers found, however, that more than a quarter of the health departments surveyed were the sole safety-net providers in their jurisdictions and that this was more likely to be the case in smaller jurisdictions (Keane et al., 2001). Distribution (percent) of Sources of Payment for Mental Health/Substance Abuse Treatment, by Type of Use, 1996. The 1998 IOM report America's Children: Health Insurance and Access to Care found that uninsured children are more likely to be sick as newborns, less likely to be immunized as preschoolers, less likely to receive medical treatment when they are injured, and less likely to receive treatment for illness such as acute or recurrent ear infections, asthma and tooth decay (IOM, 1998: 3). Studies of the use of preventive services by Hispanics and African Americans find that health insurance is strongly associated with the increased receipt of preventive services (Solis et al., 1990; Mandelblatt et al., 1999; Zambrana et al., 1999; Wagner and Guendelman, 2000; Breen et al., 2001; O'Malley et al., 2001). DoD's dual health care mission is carried out through a direct care system that comprises 530 Army, Navy, and Air Force Military Treatment Facilities (MTFs) worldwide. Systematic attention to patients' need for information and behavioral change. These trends do not appear to be a temporary, cyclical phenomenon. 2001. What are the 4 healthcare delivery system components? The involvement of AHCs in the communities is also likely to increase in the coming years. Ayanian JZ, Weissman JS, Schneider EC, Ginsburg JA, Zaslavsky AM. For children, too, being uninsured tends to reduce access to health care and is associated with poorer health. NACCHO (National Association of County and City Health Officials). Aiken L, Clarke S, Sloane D, Sochalski J, Busse R, Clarke H, Giovannetti P, Hunt J, Rafferty A, Shamian J. Coverage Matters, 2001. Health According to the Department of Health and Human Services (DHHS) Office of Health Promotion and Disease Prevention, more than 150 million Americans have limited or no dental insurance, nearly four times the number who lack insurance for medical care (cited by Allukian, 1999). However, the focus on these two health care professional shortage areas does not suggest the absence of problems in other fields. 1999. In addition, the authority of state health departments in quality monitoring, licensure, and rate setting can cause serious tensions between them and health care organizations. Changes in the financing and delivery of health care services, such as the emphasis on cost controls and the almost complete conversion to managed care for the delivery of services under Medicaid, may be especially problematic for racial and ethnic minorities. Patients regularly spent significant portions of their admission on gurneys in a hallway. Inpatient care including emergency care, labor and delivery, intensive care, diagnostic imaging For example, African Americans and members of other minority groups who are diagnosed with cancer are more likely to be diagnosed at advanced stages of disease than are whites (Farley and Flannery, 1989; Mandelblatt et al., 1991, 1996; Wells and Horm, 1992). This change has been a challenge to the multiple roles of public health departments as community-based primary health care providers, safety-net providers, and providers of population-based or traditional public health services. In addition to the linkages between the health care delivery system and governmental public health agencies, health care providers also interface with other actors in the public health system, such as communities, the media, and businesses and employers. Finally, virtually all states have the legal responsibility to monitor the quality of health services provided in the public and private sectors. The committee recommends that bold, large-scale demonstrations be funded by the federal government and other major investors in health care to test radical new approaches to increase the efficiency and effectiveness of health care financing and delivery systems. Crossing the Quality Chasm (IOM, 2001b) examined health system failures that compromise the quality of care provided to all Americans. In Edmunds M, editor; , Coye MJ, editor. By educating ourselves on the problems that we face, and the solutions that other nations around the world are using, there's a better chance that healthcare . 2. in the nursing interventions classification, a nursing intervention defined as monitoring and management of the patient during pregnancy to prevent complications of pregnancy and promote a healthy outcome for both mother and infant. (Additional discussion of these and other neglected forms of care appears later in this chapter.). In this section, the committee reviews concerns about the barriers to health care that are raised by the lack of health insurance and by threats to the nation's safety-net providers. Collect and report data on health care access and utilization by patients' race, ethnicity, socioeconomic status, and, where possible, primary language. This adds to potential tensions with the public health system. Enhanced information technology also promises to aid patients and the public in other ways. Approach: General health promotion. Facts About Mental Illness. Despite this, 28 percent of local public health departments report that they are the sole safety-net providers in their communities (Keane et al., 2001). Insurance. Insurance plans and providers scramble to adapt and survive in a rapidly evolving and highly competitive market; and the variations among health insurance planswhether public or privatein eligibility, benefits, cost sharing, plan restrictions, reimbursement policies, and other attributes create confusion, inequity, and excessive administrative burdens for both providers of care and consumers. As might be expected, though, adults without health insurance are the least likely to receive recommended preventive and screening services or to receive them at the recommended frequencies (Ayanian et al., 2000). CMS (2002a); CMS (2002a); CMS (2002c). 1999. 1993. Bone mass measurements for people at risk of losing bone mass, Colorectal cancer screening (people age 50 and older), Diabetes services (coverage of self-management training and glucose monitoring supplies) for people with diabetes, Mammogram screening (women age 40 and older), Prostate cancer screening (men age 50 and older), Vaccinations (flu, pneumococcal pneumonia, hepatitis B), Outpatient nutrition counseling by registered dietitians for patients with diabetes and some types of kidney disease.
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