Chapter 1

1. Chapter 1-Health Care USA

2. Chapter 1 Overview of Health Care:A Population Perspective Chapter 1-Health Care USA

3. 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 Chapter 1-Health Care USA

4. 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 Chapter 1-Health Care USA

5. 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 Chapter 1-Health Care USA

6. 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 Chapter 1-Health Care USA

7. 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 Chapter 1-Health Care USA

8. 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 Chapter 1-Health Care USA

9. 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 Chapter 1-Health Care USA

10. 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. Chapter 1-Health Care USA

11. 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. Chapter 1-Health Care USA

12. 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 Chapter 1-Health Care USA

13. Understanding Health Care (2) • “New” System - Government, private insurers, employers (purchasers), public advocacy groups & industry watchdogs investigate, evaluate & expose inadequacies and inequities Chapter 1-Health Care USA

14. 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… “Cook-book” medicine resistance to standardization Chapter 1-Health Care USA

15. 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 Chapter 1-Health Care USA

16. Patient & Provider Behaviors • Patients’ “Illness Behavior” (Sick Role): - not responsible for illness - exempt from normal social functioning - no responsibility for cure - dependent upon provider Chapter 1-Health Care USA

17. 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 Chapter 1-Health Care USA

18. 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 Chapter 1-Health Care USA

19. 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) Chapter 1-Health Care USA

20. 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 Chapter 1-Health Care USA

21. Major Health Care Stakeholders (2) • Hospitals, facilities: AHA, others • Governments: Federal, state • Managed care, insurance organizations • Voluntary agencies • Health professions education, training institutions • Health industries, e.g. pharmaceutical Chapter 1-Health Care USA

22. Major Health Care Stakeholders (3) • Complimentary & Alternative Therapists • Long term care industry • Mental Health services industry • Research communities Chapter 1-Health Care USA

23. 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 Chapter 1-Health Care USA

24. 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? Chapter 1-Health Care USA

25. 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 Chapter 1-Health Care USA

26. 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 Chapter 1-Health Care USA

27. 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) Chapter 1-Health Care USA

28. 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 Chapter 1-Health Care USA

29. 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 Chapter 1-Health Care USA

30. 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.) Chapter 1-Health Care USA

31. 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. Chapter 1-Health Care USA

32. 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 Chapter 1-Health Care USA

33. 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 Chapter 1-Health Care USA