Transcript Overview - Virginia Commonwealth University

Chapter 1-Health Care USA
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Chapter 1
Overview of Health Care:
A Population Perspective
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CHAPTER OBJECTIVES
• Provide a broad overview of the major
dimensions of the health care industry
• policymakers
• values
• priorities
• stakeholders
• Gain familiarity with general industry issues
and changing trends
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What Is Changing?
• Economic & social changes altering the
public’s view of providers, facilities, services
• Providers, insurers, institutions have become
commercial entrepreneurs
• Health care ~16% of GDP, $2+ trillion
• Major conflicts among providers,
policymakers and insurers
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Many Frustrations….
• Physicians: allege insurers constrain fees without
adequate regard for quality
• Policymakers: Allege providers resist accountability
and transparency
• Insurers: Providers resist evidence-based guidelines
• Patients: Confront a confusing payment system &
disjointed services
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Problems of Health Care
• Inexplicable contradictions in objectives
(e.g. prevention vs. intervention)
• Unwarranted variations in performance
• Ineffectiveness (lack of evidence)
• Inefficiency (overuse & duplication)
• Difficult relationships with public and
governments
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Reform Efforts: A 50 Year History
– 1960s: increased access for low-income
populations & older Americans
– 1970s-1980s: controls to slow cost growth
– 1990s: more cost controls + quality
improvements; market influences
– 2010 and beyond: cost, quality & access;
Patient Protection & Affordable Care Act
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Cost, Quality and Access
• Strategies to address cost, quality & access
reflect periodic changes in political
philosophies
• 1960’s government programs improved
access for aged, poor, without regard for
costs… later, access, price, quality
regulations.
• Patchwork of government reforms replaced
by market forces
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The Health Care Situation
“The quest for greater efficiency in the delivery of
health care services is eternal in a country that spends
far more on health care than any other, consistently
has growth in spending that outstrips that of income,
is unable to provide insurance coverage to at least
15% of its population and ranks poorly...in life
expectancy and infant mortality.”
L. M. Nichols, 2004
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The Reform Dilemma…
• General acknowledgement that system is in need of
major reforms
• Americans have been unwilling to risk health system
strengths to produce needed reforms
• Government, employers, providers, insurers, the
public cannot agree on how to improve the system.
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Legislative vs. Market-driven
Reforms
• Legislative proposals: try to balance cost,
quality, access without risking system
strengths to remedy weaknesses
• Primary market goal: contain costs
• Public: unable to judge benefits/risks of
proposed remedies.
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Understanding Health Care (1)
• “Old” System
– Practitioners fostered mystique to preserve
distinguished status from patients &
encourage blind faith
- Confidential provider/patient contract, not
subject to outside review
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Understanding Health Care (2)
• “New” System
- Government, private insurers, employers
(purchasers), public advocacy groups &
industry watchdogs investigate, evaluate &
expose inadequacies and inequities
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Understanding Health Care (3)
• Public cynicism spawned by widespread exposure
to inadequacies of the health care system;
recognition of major knowledge gaps
• Movement toward “evidence-based” practice slow
in gaining traction among practitioners… “Cookbook” medicine resistance to standardization
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Understanding Health Care (4)
• Health providers discouraged by budget
constraints & regulation
• Financial & regulatory requirements at odds
with professional, patient-centered values
– Impacts on nursing causing many to leave
profession
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Patient & Provider Behaviors
 Patients’ “Illness Behavior” (Sick Role):
- not responsible for illness
- exempt from normal social functioning
- no responsibility for cure
- dependent upon provider
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New Patient Expectations
Challenge Providers
• Patients
– Prepared with media & internet information
– Informed questioning about diagnoses, treatment
options
– Concerned about costs
• Providers: Difficult adaptations to patient information
access and empowerment
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Indices of Health and Disease
• Definition of “Health” is subjective and illusive
• 1958 WHO definition: “A State of complete
physical, mental and social well-being, and not
merely the absence of disease.”
• U.S.: 37th in world ranking; does not compare
favorably on major parameters, e.g.
infant/maternal mortality with other developed
countries
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Natural Histories of Disease &
Levels of Prevention
• A matrix of the evolutionary stages of disease
and the points at which health care services can
intervene to:
– prevent disease onset (Primary Prevention)
– Attenuate disease progression (Secondary
Prevention)
– Rehabilitate (Tertiary prevention)
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Major Health Care Stakeholders (1)
Periodically, groups may support or oppose specific
reform proposals or other issues:
• The Public
• Consumer (AARP) & disease-specific groups
• Large, small employer coalitions (purchasers)
• Providers: AMA, other professional organizations
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Major Health Care Stakeholders (2)
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Hospitals, facilities: AHA, others
Governments: Federal, state
Managed care, insurance organizations
Voluntary agencies
Health professions education, training institutions
Health industries, e.g. pharmaceutical
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Major Health Care Stakeholders (3)
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•
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Complimentary & Alternative Therapists
Long term care industry
Mental Health services industry
Research communities
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Rural Health Services
• Rural systems often incomplete: service
shortages and duplications
• Federal, state programs: rural networks for
primary care, links to regional specialists,
tertiary care, e.g. critical access hospitals
• Rural hospital closures yield health &
economic consequences
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Tyranny of Technology
• As technology advances, costs rise with more
people denied of benefits
• Providers fond of technological ingenuity
• Best providers, technology often dedicated to
futile terminal care
• Patient benefit, cost-effectiveness, outcome
improvement?
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Social Choices
• Health care system emphasis on cure, fails to
lead prevention
• Health professionals’ prestige and influence
lacking in steering public opinion &
governmental action to address dangerous
practices, e.g. substance abuse, sexual
behaviors
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Emerging Issues and Challenges (1)
• Aging population: by 2050, >30% over 65,
85+ will double:
– Increased longevity, immigration, culturally
diverse aged
– Major gaps in delivery system appropriateness
for care of older, culturally diverse Americans
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Emerging Issues, Challenges (2)
– Many more culturally sensitive, geriatric
providers needed
– Services for chronic disabilities, functional
limitations of aging not addressed by
Medicare or private plans
– Nursing home care major financial burden
(personal & government)
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Emerging Issues, Challenges (3)
• Aging population is not the only dilemma:
– Gradual changes in age distribution will have a
less dramatic effect on the delivery system than
technology development and workforce shortages.
Uwe Reinhardt
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Emerging Issues, Challenges (4)
• Access to Care
– Polar public and policymaker viewpoints on
entitlement to basic health care: ensure access
without government interference with private
practice or consumer choice
– Resolution requires public, other major
stakeholders’ consensus on values
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Emerging Issues, Challenges (5)
• Quality of Care
– Medical errors & infections
– Appropriateness & overuse of care
– Opaque system
• Conflicts of Interest
– Commercialism in related health care businesses
(investor- owned labs, imaging centers, etc.)
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Ethical Dilemmas (1)
• Issues arise from treatment options, domains
of law, politics, journalism, administration,
public, providers.
• Issues expand with genetic advances, organ
transplantation, life-prolonging technologies,
etc.
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Ethical Dilemmas (2)
• Consumers advocate control over decisions;
appropriate use of limited resources emerging
at top of agenda.
• Policymakers prefer to deal with dilemmas
piecemeal & short-term
• Pluralistic society, Judeo-Christian values
make major reforms difficult
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Conclusion
• Increased longevity, technological advances place
new demands on system
• Access, cost, quality issues persist
• New concerns: improving health behaviors, consumer
involvement, medical management responsibility, e.g.
“medical homes”
• Transparency of quality information
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