Download Health Care Delivery - Thomas-Estabrook

Health Care Delivery
Questions
• 1. What is the number one health care
problem in your community or hometown?
• 2. What should be done to address this
problem?
Introduction
• Health care delivery: variety of providers and
settings.
• Haphazard conglomeration: providers,
facilities, agencies, programs.
Brief History of Health Care Delivery in U.S.
• Pre-1850: mainly at home
• 1850- early 1900s: move to doctor’s
offices, hospitals.
– Science had bigger role in medical education
– Mortality decline due to improved public
health measures.
• Early 1900s: scientific advancements
improve medical practice, instruments
– X-ray, specialized surgery, chemotherapy, ECG
Health Care Delivery – 1920s1940s
• 1929 – 3.9% GDP on health care
• 1920s: Two party system – patients and
physicians
– Physicians collected own bills, set prices on ability
to pay.
• World War II impact: due to wage restrictions
employers used health insurance to lure workers.
• Taft-Hartley Act (1946) – Labor/management
compromise: employer-provided health insurance in
exchange for no strikes.
Health Care Delivery – 1940s1950s
• Huge technical strides in 1940s-50s.
• Hill-Burton Act (1946): new hospital
construction.
• New hospitals, equipment  rising health
care costs.
• Concept of health care as basic right vs.
privilege (starts with FDR)
Health Care Delivery – 1960s
• Late 1950s – shortage of quality care,
maldistribution of services.
• Rising costs, 1950s-60s  greater interest in
health insurance, third party payments.
• Mushrooming third party payments, as standard
method of payment  increases in medical costs.
• Early 1960s, medical advances not reaching large
part of population: elderly, poor.
• Medicare and Medicaid (1965) authorized for poor
and elderly.
Health Care Delivery – 1970s
• Health care crisis: still 30 million without
insurance.
• Health Maintenance Organization Act of 1973:
establishes HMO system.
• National Health Planning and Resources
Development Act of 1974
– Health Systems Agencies in place to cut costs and
prevent building unnecessary facilities and
purchasing unnecessary equipment
Health Care Delivery – 1980s
• Reagan and Congress eliminated Health
System Agencies
• Deregulation of health care delivery 
neoliberal (free-market) policy
• Proliferation of new medical technology
• Result is failure to control rising costs.
• Questions in medical ethics
• Elaborate health insurance programs
Health Care Delivery – 1990s
• Clinton effort to create universal health care
fails  huge resistance from industry, Congress.
• American Health Security Act of 1993
• Managed care
– Achieve efficiency
– Control utilization
– Determine prices and payment
• 1996 – U.S. health care is 13.6% GDP ($1 trill.)
• Children’s Health Insurance Program (CHIP)
• Consumer bill of rights introduced, stalls.
Health Care Delivery in
st
21
Cent.
• Medicare Modernization Act (2003):
huge
federal subsidy to companies for retiree medications;
prohibits govt. negotiating discounts with drug companies. 
a windfall for Pharma industry.
• Health care is 16.2% of GDP (2006), 17.3% of
GDP (2009, = $2.6 trill.)
– Health care costs outpacing inflation for past few decades
– America spends more per capita annually on health care
than any other nation
• Still no national Patient Bill of Rights
• Health Savings Accounts
• 2010 – Affordable Care Act
Brief History of Health Care Delivery
in the U.S. - 8
Spending 3.9% of GDP on health
Pre- 1900 1911 1918 1929
187
0
Brief History of Health Care Delivery
in the U.S. - 9
• Diagnosis, treatment, fee
• WWII & medical advances
• Hill-Burton Act
• Taft-Hartley Act
Pre- 1900 1911 1918 1929 1930s
187
& 1940s
0
Brief History of Health Care Delivery
in the U.S. - 10
• Right or privilege
• Overall shortage & maldistribution
• 3rd party system takes hold
• Medicaid & Medicare
Pre- 1900 1911 1918 1929 30s/40s
187
1950s & 60s
0
Brief History of Health Care Delivery
in the U.S. - 11
• Cost containment
• Health planning agencies
• HMO Act 1973
Pre- 1900 1911 1918 1929 30s/40s 1970s
187
50s/60s
0
Brief History of Health Care Delivery
in the U.S. - 12
• Deregulation
• New medical technologies
Pre- 1900 1911 1918 1929 30s/40s 70s
1980s
187
50s/60s
0
Brief History of Health Care Delivery
in the U.S. - 13
• American Health Security
Act of 1993
• Managed care
• Costs hit $1 trillion
1990s
Pre- 1900 1911 1918 1929 30s/40s 70s
187
50s/60s 80s
0
Brief History of Health Care Delivery
in the U.S. - 14
• Medicare Modernization Act of 2003
• Health Savings Accounts
• No patients’ bill of rights
• GDP 16.2%
90s
Pre- 1900 1911 1918 1929 30s/40s 70s
80s 2000s
187
50s/60s
0
Spectrum of Health Care Delivery
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•
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Population-based public health practice
Medical practice
Long-term practice
End-of-life practice
Spectrum of Health Care Delivery
• Population-based Public health practice:
aimed at disease prevention, health
promotion.
– Education is primary: empowerment, motivation.
– Much in government agencies; also in voluntary
agencies, social services, schools, companies,
traditional medical care.
Medical Practice
• Under physician or other traditional provider.
• Primary medical care: front-line care,
comprehensive, person-centered, first-contact
care; ongoing care for common treatments.
– Providers: physicians, dentists, pediatric nurse
practitioners, etc.
– Setting: clinics, practitioners’ offices, outpatient
facilities.
Spectrum of Health Care Delivery
– Other primary health services:
•
•
•
•
•
•
•
•
Safe food supply
Clean water
Control of communicable diseases
Maternal and child health care
Provision of essential drugs
Control of local diseases
Health education, including proper nutrition
immunizations
Spectrum of Health Care Delivery
• Secondary medical care: attention and
management of common medical conditions
– Example: intense diagnosis/treatment, such as
setting a broken bone.
– Provided by physician, upon referral.
– Setting: hospital, outpatient clinics, emergency
rooms
Spectrum of Health Care Delivery
• Tertiary medical care
– Highly specialized and technologically
sophisticated medical and surgical care.
– For unusual and complex conditions
– Treatments for heart disease, cancer, AIDS, etc
– Provided by specialist physician
– Setting: large hospital with trained staff
Spectrum of Health Care Delivery
• Long-term medical practice
• Restorative care: recovery, rehabilitative care
– Care after surgery, stroke, cancer treatment
– Providers: nurses, allied health professionals
– Setting: rehab units of large hospitals, nursing
homes, halfway houses, private homes
Spectrum of Health Care Delivery
• Long-term health care
– Chronic health problems and disabilities, physical
or mental, often old-age.
– Time-intensive skilled care to basic daily tasks
– Setting: nursing homes, state hospitals, halfway
houses, private homes
• End of life practice: for patients with less
than six months to life. Hospice practices
Types of health care providers
• 14.5 million, 10.4 % of civilian workforce
• 41% in hospitals; 26% in ambulatory care
facilities; 16% in nursing/residential facilities.
• Growing rapidly. 200 professions:
– Independent providers: can treat any health problem.
– Limited care providers
– Nurses
– Non-physician practitioners
– Allied health care professionals
– Public health professionals
Independent providers
• Specialized education and legal authority to
treat any health problem or disease
• Allopathic and osteopathic providers
• Non-allopathic providers: non-traditional
practitioners
Allopathic and Osteopathic Providers
• Allopathic providers
– Produce effects different from those of diseases
– Doctors of Medicine (MDs)
• Osteopathic providers
– Relationship between body structure & function
– Doctors of Osteopathic Medicine (DOs)
• Similar education and training
• Most DOs work in primary care
Nonallopathic Providers
• Nontraditional means of health care
• Complementary and Alternative medicine
(CAM)
– Used together with conventional medicine,
therapy is considered “complementary”; in place
of considered “alternative”
– Chiropractors, acupuncturists, naturopaths, etc.
– Natural products, mind-body medicine,
manipulation, etc.
Limited (or Restricted) Care Providers
• Advanced training in a health care specialty
• Provide care for a specific part of the body
• Dentists, optometrists, podiatrists,
audiologists, psychologists, etc.
Nurses
• Over 4 million working in nursing profession
• Licensed Practical Nurses (LPNs)
– 1-2 years of education in vocational program
– Pass licensure exam
• Registered Nurses (RNs)
– Completed accredited academic program
– State licensure exam
• Advanced Practice Nurses (APNs)
– Master or Doctoral degrees
Nonphysician Practitioners
• Practice in many areas similar to physicians,
but do not have MD or DO degrees
• Training beyond RN, less than physician
• Nurse practitioners, certified midwives,
physician assistants
Allied Health Care Professionals
• Assist, facilitate, and complement work of
physicians and other health care specialists
• Categories
– Laboratory technologist/technicians
– Therapeutic science practitioners
– Behavioral scientists
– Support services
• Education and training varies
Public Health Professionals
• Work in public health organizations
• Usually financed by tax dollars
• Available to everyone; primarily serve
economically disadvantaged
• Public health physicians, environmental health
workers, epidemiologists, health educators,
public health nurses, research scientists, clinic
workers, biostatisticians, etc.
Health Care Facilities
• Practitioners’ offices
• Medical clinics: very small to large
• Hospitals: public, private, voluntary,
governmental
• Ambulatory care centers
• Rehabilitation centers
• Continuing care facilities.
Inpatient Care Facilities
• Hospitals, nursing homes, assisted-living
• Hospitals often categorized by ownership
– Private – profit making; specialty hospitals
– Public – supported and managed by government
jurisdictions
– Voluntary – not-for-profits; ½ of U.S. hospitals
• Teaching and nonteaching hospitals
• Full-service or limited-service hospitals
Clinics
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Two or more physicians practicing as a group
Do not have inpatient beds
For-profit and not-for-profit
Tax funded
– Public health clinics, community health centers
– Over 1,100 community health centers in U.S.
– Support primary health care needs of underserved
populations in the U.S.
Outpatient Care Facilities
• Care in a variety of settings, but no overnight
stay regardless of why patient is in the facility
– Health care practitioners’ offices, clinics, primary
care centers, ambulatory surgery centers, urgent
care centers, services offered in retail stores,
dialysis centers, imaging centers
Rehabilitation Centers
• Work to restore function
• May be part of a clinic or hospital, or
freestanding facilities
• May be inpatient or outpatient
Long-Term Care Options
• Nursing homes, group homes, transitional care,
day care, home health care
• Home health care
– Growing due to restructuring of health care
system, technological advances, and cost
containment
Accreditation of Health Care
Facilities
• Assists in determining quality of health care
facilities
• Process by which an agency or organization
evaluates and recognizes an institution as
meeting certain predetermined standards
• Joint Commission
– Predominant accrediting organization
Health Care System Function
• U.S. “system” unique compared to other countries
– Recent decades’ challenges led to new legislation
• Affordable Care Act
– Goal: to put American consumers back in charge
of their health coverage and care
– Signed into law March, 2010; changes to be
implemented 2010-2020; some effective mid2010; bulk go into effect 2014
Structure of the Health Care
System
• U.S. structure – complex, expensive, many
stakeholders, intertwined policies, politics
• Major issues:
– Cost containment, access, quality
• All equally important; expansion of one compromises
other two
Health Care System: Function
• U.S. health care system among the best in the
world.
• Many people don’t have access
Access to Health Care
• Only 83% have access to complete care.
• Many don’t have access to primary care.
• Factors limiting access to health care: lack of
health insurance, poverty.
Paying for Health Care
• Largest American expenditure: $ 7,129 per
person per year, 2006; 16.2% of GDP
• Sources of health care payments:
– Direct or out-of-pocket payments
– Third party payments:
• Private insurance
• Public funds
• Private funds
Paying for Health Care
• Fee for service system indemnity
• Pre-paid health care (capitation): paying
ahead for treatment.
• System of third-party payments: funds
collected as insurance premiums or taxes.
Health Insurance
• 47 million without health insurance
• State Childrens Health Insurance Program (SCHIP),
1997. Intended to cover 11.6 mill. children, really 6.1
mill. (2005)
• Health insurance policy: between individual and
insurance company. 61% of employers provided
insurance (2006), vs. 69% (2000).
• Employers shifting costs to employees: eg. GM, Ford.
• Key terms: deductible, co-insurance, co-payment,
fixed-indemnity, exclusion, pre-existing condition.
Health Insurance
• Health Insurance Portability and
Accountability Act (1996)
• Types of health care coverage:
– hospitalization; surgical; regular medical; major
medical; dental; disability (income protection);
optical
• Cost of Health Insurance
Government Health Insurance
• Insurance for specific populations: elderly,
poor, veterans, Native Americans, military
• Medicare:
– Health Care Financing Admin.
– Part A (hospital), part B (medical)
• Medicaid: insurance for the poor
Supplemental Medical Coverage
• Medigap coverage
• Optional supplemental insurance (private)
• Long-term care insurance
Managed Care
• Around since 1973, took hold in 1990s; 176 mill.
enrolled (2005)
• Preferred Provider Organizations (PPOs)
• Exclusive Provider Organizations (EPOs)
• Health Maintenance Organizations (HMOs):
health care insurance + delivery of medical
services
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–
–
–
Staff model HMO
Group model HMO
Network model HMO
Independent practice association model HMO
Managed Care - 3
• Types of managed care
– Preferred provider organizations (PPOs): closest to
fee-for-service; agreement between provider &
organization to provide service to members for
discounted rate
– Exclusive provider organizations (EPOs): like a
PPO but with stronger financial incentives
– Health Maintenance Organizations (HMOs): oldest
form; combines insurance & medical care; uses
primary care physicians & prepaid health care
arrangement
Managed Care
• Types of managed care
– Point-of-Service Option (POS): associated with
HMOs & allows for more liberal policy in selecting
providers
– Physician-Hospital Organizations (PHOs):
arrangements between physicians & hospitals to
negotiate with insurers as MCOs
– Medicare Advantage: HMO option of Medicare; not
available everywhere
– Medicaid & managed care: most states use; 61% of
people covered in Medicaid are in managed care
Managed Care
• Advantages of managed care
– Comprehensive benefits
– Evidence-based high-quality care
– Well-documented services provided through
integrated delivery systems
– Accountability for quality improvement
• However, many Americans are still worried
about health care
Managed Care
• Concerns of managed care
– Not managed care but “managed cost”
– Authorizing only certain practitioners under contract
– Reviewing treatment decisions
– Closely monitoring high-cost cases
– Reducing inpatient stays
– Using lower cost alternative treatments
– Delays in receiving care
– Cannot understand bills
National Health Insurance Systems
• Federal govt. insures availability of health care
for all people.
• Paid for by tax dollars.
• Most developed countries.
• Congress has considered this many times. Not
likely soon
Canadian Health Care System
• Universal access first, cost second.
• Each province must assure universal access.
• Cost paid by combination of public funding
coming from provincial, federal, corporate
taxes, private funding.
• Physicians are independent providers.
• Emphasis on prevention, primary care, less
emphasis on specialized care.
Americans Spend More Out-of-Pocket
on Health Care Expenses, 2004
53
Total health care spending per capita
$7,000
United States
$6,000
$5,000
$4,000
France
Netherlands
$3,000
$2,000
Canada
Germany a
OECD Median
Australia b
Japan a
New Zealand
$1,000
$0
$0
$100
$200
$300
$400
$500
$600
Out-of-pocket spending per capita
a2003
b2003
Total Health Care Spending, 2002 OOP Spending
Source: The Commonwealth Fund, calculated from OECD Health Data 2006.
$700
$800
$900
Oregon Health Plan
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Addresses cost first, access follows
High-priority services paid first.
Citizens prioritized health care needs.
Waiver needed from federal government
Successful plan
Affordable Health Care Act 2010
• Federal rules prohibiting restricting coverage and varying
premiums based on health.
• New health insurance exchanges.
• Affordability for low and middle income families.
• Commitment to shared responsibility: employer coverage, tax
credits, individual mandate.
• Improvements to Medicare prescription drug benefits.
• Creates new long-term care financing program.
• Investment in stronger primary care foundation.
• Creation of innovation center within Medicare/Medicaid.
• Creation of Independent Payment Advisory Board.
• Investment in health care infrastructure (IT, etc.)
Inhuman Health Care
(Vicente Navarro)
• Uninsured: 47 mill. uninsured people in U.S.
• Almost 100,000 die annually because of lack
of needed care. Media silent.
• Underinsured: Inadequate health insurance,
for most people (250 mill.). Very difficult for
elderly and terminally ill.
Inhuman Health Care
• Reasons for health care crisis in U.S.
– Class power, the most important category of power. Class
mortality differentials are largest.
• Ownership class (upper class): large owners, CEOs
• Upper middle class: mid-size owners, professionals
• Middle class: craft workers, artisans, self-employed, tech. and
admin. personnel.
• Working class: clerical, manufacturing, service; hourly workers.
Inhuman Health Care
• Reasons for health care crisis in U.S.
– U.S. has no national health insurance, rather most
insurance in through employer.
• Due to Taft-Hartley Act (1946): health benefits through
collective bargaining agreements.
• Even best workplace benefits are worse than health
care in other capitalist countries.
• Workers paying increasing share for health care.
• Taft-Hartley disciplines workers: you get fired, you lose
your health care benefits.
Inhuman Health Care
• Reasons for health care crisis in U.S.
– Labor weakened through Taft-Hartley Act: no sympathy
strikes. Unlike any other country. Labor lacking enormous
power of strikes, to force health care reform.
– Class power: corporate class has great power in U.S.
politics. Overwhelming corporate class in Congress,
cabinet. Few working class (and progressive)
congresspeople.
– Corporate control of health care institutions: universities,
hospitals have corporate class board members, almost no
working class people.
Inhuman Health Care
• Reasons for health care crisis in U.S.
– Pushing for changes in class composition  meets
more opposition than race, gender demands.
– Privatization of electoral process: “money is the
milk of politics.” Corporate money to influence
health care decisions.
– U.S. has many social movements, but inefficient
and single-issue focus. Working class is weak,
labor movement is weak.
Inhuman Health Care
• Lessons:
– Strong social movement (including labor
movement) are key to challenging corporate
power, in health care and elsewhere.
– Unite the diversity of social movements in
common struggles: this can help to improve
public health.
Health Care Reform in U.S.
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•
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Needs to be universal
Needs to be continuous
Coverage needs to be affordable
Insurance should enhance health and wellbeing.
Summary
• Health care delivery is increasingly expensive:
technology, insurance industry, aging
population.
• Health care costs are ever greater burden for
public and private employers.
• Costs are increasingly shifted to employees
(and unions)  higher premiums, less
coverage.
Summary
• Market-based health care is failing to cover
people adequately (47 mill. Uninsured; >168
mill. Underinsured)
• Elite class influence on health care 
maintains market-driven system
• Social contract is weak and broken
• Dilemma: How to fight for universal coverage
within a market-based system?
• Stronger social movements needed to fight for
universal health care.