4 components of health care delivery system 4 components of health care delivery system

That report emphasized that untreated health problems can affect children's physical and emotional growth, development, and overall health and well-being. 2002. In addition, support groups and interactive programs offer additional approaches to empower consumers. (Ed.). However, the USPSTF recommendations have had relatively little influence on the design of insurance benefits, and recommended counseling and screening services are often not covered and, consequently, not used (Partnership for Prevention, 2001) (see Box 53). The resources of the health care delivery system are not balanced well enough to provide patient-centered care, to address the complex health care demands of an aging population, to absorb normal spikes in demand for urgent care, and to manage a large-scale emergency such as that posed by a terrorist attack. It is also associated with having a regular source of care and with greater and more appropriate use of health services. Concierge medicine, according to Healthline, is a new healtchare delivery system that's quickly gaining traction. Recent surveys have found that less than half of U.S. patients with hypertension, depression, diabetes, and asthma are receiving appropriate treatments (Wagner et al., 2001). 1998. 2001. Children's Preventive Health Care under Medicaid. Insurance. 2001. Reinhardt UE, Hussey PS, Anderson GF. U.S. Department of Housing and Urban Development. Burn care beds and other special care beds intended for care that is less intensive than that provided in an ICU and more intensive than that provided in an acute care area. The consequences in terms of individual and population health are significantoral health is a matter of public health concern because it affects a large proportion of the population and is linked with overall health status (see Box 57). Furthermore, rapid turnover in enrollment, particularly in Medicaid managed care, ruined economic incentives for plans to view their enrollees as a long-term investment. 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. 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. . Johnson R, editor; , Morris TF, editor. Physicians are proving more aggressive and successful in their negotiations with plans to decrease constraints, and to date, most employers have been willing to accept the higher costs that result. The result is poor disease management and a high level of wasted resources. Figure 1-1 illustrates that a health care delivery system incorporates four functional componentsfinancing, insurance, delivery, and payment, or the quad-function model. The level of use of preventive services among older adults has been relatively low (CDC, 1998). HELP (Health & Education Leadership for Providence). tailored to your instructions. Nearly 90 percent of employers' most popular plans cover well-baby care, whereas less than half cover contraceptive devices or drugs to prevent unwanted births. 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 facts about uninsurance in America are sobering (see Box 51). Predicting the next configuration of insurance and plan delivery systems is dangerous in a system undergoing such rapid transition. The participant rate. The Chronic Care Model [3,4,5] is a well-established organizational framework for chronic care management and practice improvement. Boards of Trustees (2002). To outline the four key functional components of a health care de-livery system To discuss the primary characteristics of the US health care system from a free market perspective To emphasize why it is important for health care managers to under-stand the intricacies of the health care delivery system To get an overview of the . 1998. The shortage of hospital-based nurses reflects several factors, including the aging of the population, declining nursing school enrollment numbers (Sherer, 2001), the aging of the nursing workforce (the average age increased from 43.1 years in 1992 to 45.2 years in 2000) (Spratley et al., 2000), and dissatisfaction among nurses with the hospital work environment. Academic health centers (AHCs) serve as a critical interface with governmental public health agencies in several ways. Governmental public health agencies may also play an important role in preventive medicine and public health education. 1. New federal regulations regarding the confidentiality of medical records, required by the Health Insurance Portability and Accountability Act (P.L. This fi gure identifi es the relationship between the four major components of the health care delivery system: Payer Providers, Regulators, and Supplies. Cost sharing may discourage early care seeking, impeding infectious disease surveillance, delaying timely diagnosis and treatment, and posing a threat to the health of the public. In 2000, 9 percent of physicians and 12.3 percent of RNs were from racial and ethnic minority groups (AAMC, 2000). Crossing the Quality Chasm (IOM, 2001b) examined health system failures that compromise the quality of care provided to all Americans. In a study analyzing more than 5 million patient discharges from 799 hospitals in 11 states, Needleman and colleagues (2001) consistently found that higher RN staffing levels were associated with a 3 to 12 percent reduction in indicatorsincluding lower rates of urinary tract infections, pneumonia, shock, and upper gastrointestinal bleeding and shorter lengths of staythat reflect better inpatient care. 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. First, managed care plans reimburse safety-net providers less generously than fee-for-service Medicaid providers do (under Medicaid, federally qualified health centers benefited from a federal requirement for full-cost reimbursement), and they impose administrative and service restrictions that result in reduced overall rates of compensation (IOM, 2000a). The recent trend of the exit of managed care from the Medicaid market has left some people without a medical home and, in cases of changes in eligibility, has left some people uninsured. Similarly, if diseases can be detected and treated when they are still in their early stages, subsequent rates of morbidity and mortality can often be reduced. Sturm R, Jackson CA, Meredith LS, Yip W, Manning WG, Rogers WH, Wells KB. These included. Furthermore, when the delivery of health care through the private sector falters, the responsibility for providing some level of basic health care services to the poor and other special populations falls to governmental public health agencies as one of their essential public health services, as discussed in Chapter 1. Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. Oral Health as a Component of Total Health. 2001. Medicaid benefits vary by state in terms of both the individuals who are eligible for coverage and the actual services for which coverage is provided. The environment in which AHCs operate has changed substantially over the past decade. Having a regular source of care improves chances of receiving personal preventive care and screening services and improves the management of chronic disease. Defined-contribution health care benefits are a new way for employers to provide health care coverage to their employees, while no longer acting as brokers between employees and insurance companies contracted to provide benefits. This is because the US health care system is fragmented with many people obtaining and receiving health care through different means. The committee found that preventive, oral health, mental health, and substance abuse treatment services must be considered part of the comprehensive spectrum of care necessary to help assure maximum health. Final Report, Networking Health: Prescriptions for the Internet, Children's Health under Medicaid: A National Review of Early Periodic Screening, Diagnosis and Treatment, Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community, Fiscal Year 2001 performance and accountability report, Driving the market to reduce medical errors through the Leapfrog California Patient Safety Initiative, Why Invest in Disease Prevention? Macinko JA, Starfield B, Shi L. [in press]. Although these steps can be expected to improve the nation's health and may even reduce costs over time, the initial investment will be substantial. After a period of stability in the mid-1990s, health care costs are again rising because of several factors (Heffler et al., 2002). Cooper-Patrick L, Gallo JJ, Powe NR, Steinwachs DM, Eaton WW, Ford DE. 1999. Such services include immunizations and screening tests, as well as counseling aimed at changing the personal health behaviors of patients long before clinical disease develops. Lumpkin JR, Landrum LB, Oldfield A, Kimel P, Jones MC, Moody CM, and Turnock BJ. Denver Health is the local (county and city) public health authority, as well as a managed care organization and hospital service. 1999. The American Health Care System as a Non-System. Contrary to popular belief, recent immigrants accounted for a relatively small proportion of the uninsured (less than one in five). Preventive Services Covered by Medicare. IHS (2002a, 2002b). Notifiable disease reporting systems within public health departments with strong liaisons with the health care community are important in the detection and recognition of bioterrorism events. Vignettes drawn from the experience of American Hospital Association NOVA Award recipients illustrate the importance of investing in overall community health (AHA, 2002). Protection against specific illnesses. 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. The same effects have been shown for the use of behavioral health care services (Wells et al., 2000). health management associates accountable care institute 180 north lasalle, suite 2305, chicago, illinois 60601 telephone: 312.641.5007 fax: 312.641.6678 www.healthmanagement.com pat terrell, executive director terry conway, md, director of clinical practice doug elwell, director of finance art jones, md, director of finance greg vachon, md, director of clinical practice Nevertheless, as the NCVHS report describes, neither the opportunities nor the barriers to the development of the NHII are related solely to information technology. As with other forms of safety-net care, the urgency of providing treatment to the severely mentally ill erodes funds available for prevention purposes. HRSA (Health Resources and Services Administration). 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). 2002. False Collect and report data on health care access and utilization by patients' race, ethnicity, socioeconomic status, and, where possible, primary language. 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. As the proportion of old and very old increases, the system-wide impact in terms of cost and increased disability may well overwhelm the human and financial resources available to care for chronically ill patients. About 40 million people (more than one in five) ages 18 to 64 are estimated to have a single mental disorder of any severity or both a mental and an addictive disorder in a given year (Regier et al., 1993; Kessler et al., 1994). However, the basic functional components include running the system, the different branches of the system, how services are rendered, how the services are funded, and manufacturing of new products (Barton, 2010, p. 6-8). Even when insured, limitations on coverage may still impede people's access to care. In 1988, about three-quarters of adults with employment-based health insurance had a benefit package that included adult physical examinations. The organization and delivery of safety-net services vary widely from state to state and community to community (Baxter and Mechanic, 1997). It has also reduced the time that physicians spend with patients and the quality of the clinical encounter. 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. This chapter focuses on the actions that health care organizations can take to design a work system that supports the diagnostic process and reduces diagnostic errors (see Figure 6-1). In Edmunds M, editor; , Coye MJ, editor. Annual and lifetime coverage limits are frequently less, and mental health coverage often has more hidden costs in the forms of copayments and higher deductibles (Zuvekas et al., 1998). Examples of such networks are the National Nosocomial Infections Surveillance system and the National Molecular Subtyping Network for Foodborne Disease Surveillance (PulseNet). 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. 2000. Mark DH, Gottlieb MS, Zellner BB, Chetty VK, Midtling JE. As disciplines and professional fields, medicine and public health evolved with minimal levels of interaction, and often without recognition of the lost opportunities to improve the health of individuals and the population. Among physicians, about 3 percent are African American, 2.2 percent are Hispanic, and 3.6 percent are Asian (AAMC, 2000). . In a further example, the Crozer-Keystone Health System that serves Chester, Pennsylvania, was declared a distressed municipality by the state in 1994. Ultimately, such systems should also allow the public to contribute and receive information to get the most complete database possible. Health departments, for example, provide unique venues for the training of nurses, physicians, and other health care professionals in the basics of community-based health care and gain an understanding of population-level approaches to health improvement. Such plans are characterized by higher per capita resource constraints and stricter limits on covered services (Phillips et al., 2000). Hospital vacancy rates for RN positions averaged 11 percent across the country, ranging from about 10 percent to more than 20 percent in some states. The health care sector also includes regulators, some voluntary and others governmental. Why does cost containment remain an elusive goal in U.S. health services delivery? The committee endorses the call by the National Committee on Vital and Health Statistics (NCVHS) (2002) for the nation to build a twenty-first century health support systema comprehensive, knowledge-based system capable of providing information to all who need it to make sound decisions about health. The IOM committee that produced the report America's Health Care Safety Net: Intact but Endangered (IOM, 2000a: 205206) had the following findings: Despite today's robust economy, safety net providersespecially core safety net providersare being buffeted by the cumulative and concurrent effects of major health policy and market changes. For example, admission rates for asthma were 6.4 percent higher in low-income areas than in higher-income areas, with more than 70 percent of the variation explained by household income (Billings et al., 1993). Health care delivery forms the most visible function of the health system, both to patients and the general public. 1999. Financing pays for the purchase of health insurance. Legal, Regulatory, and Policy Interventions to Eliminate Racial and Ethnic Disparities in Health Care. An employer may choose from several different ways to put money into a health benefits account for each employee and offer the employee a menu of coverage options, with different funding levels and employee financial responsibility for each. Services, Consumers, Personnel, and Payment Hospitals vary in size, ownership, and types of services. Pew Environmental Health Commission. Additionally, the media may be a powerful tool for familiarizing the public with health and health care issues and a conduit for raising important questions, stimulating public interest, or even influencing the public's health behaviors. This fi gure identifi es the relationship between the four major components of the health care delivery system: Payer. When risk factors, such as high blood pressure, can be identified and treated, the chances of developing conditions such as heart disease can be reduced. CMS (Centers for Medicare and Medicaid Services). Counseling to address serious health riskstobacco use, physical inactivity, risky drinking, poor nutritionis least likely to be covered by an employer-sponsored (more). Baxter R, Rubin R, Steinberg C, Carroll C, Shapiro J, Yang A. An important opportunity was lost when insurance companies, health plans and health providers, and the state and federal governments saw managed care primarily as a cost-containment mechanism rather than a population-based approach to delivering comprehensive and effective health care services. The committee is concerned that with the escalation of expenditures, going in large measure toward maintaining current services, it will be difficult to identify the necessary public- and private-sector resources that will be needed for new activities. From the provider perspective, better information systems and more extensive use of information technology could dramatically improve care by offering ready access to complete and accurate patient data and to a variety of information resources and toolsclinical guidelines, decision-support systems, digital prescription-writing programs, and public health data and alerts, for examplethat can enhance the quality of clinical decision making. Calleson and colleagues (2002) surveyed the executives and staff of eight AHCs around the country and found that communitycampus partnerships can strengthen the traditional mission of AHCs. The committee fully endorses the recommendations from America's Health Care Safety Net: Intact but Endangered (IOM, 2000a), aimed at ensuring the continued viability of the health care safety net (see Box 52). Using delivery system innovations to advance health care reform continues to be of widespread interest. The lower quality of care also compounds the adverse health effects of other disadvantages faced by minorities, including lower incomes and education, less healthy living environments, and a greater likelihood of being uninsured. Substantial increases in health insurance premiums are a clear indication of these economic stresses. Although some of this increase is to be expected because of the overall aging of the U.S. labor force, the proportion of workers who are age 35 and older is increasing more for RNs than for all other occupations (IOM, 1996). First, as noted earlier, AHCs are an important part of the safety-net system in most urban areas. Emergency and trauma care were also found to vary for insured and uninsured patients. 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. Medical professionals such as WHO agree that embracing the 6 components of health will allow patients to lead more complete lives. For the most prevalent mental health disorders such as depression and anxiety, receipt of appropriate care is associated with improved functional outcomes at 2 years (Sturm et al., 1995), but the majority of individuals suffering from mental illness are not treated for their condition (DHHS, 1999). Each of the 6 components of health is somehow integrated, which incorporates social, physical, emotional, spiritual, cognitive, and cultural health. These areas include the regulatory and quality monitoring functions performed by governmental agencies, disease surveillance and reporting by health care providers, and the provision of safety-net services. The committee focused on the problem of insurance and access to care. As of fiscal year 1996, only nine states reported meeting or exceeding the federally established goal. Services provided by state and local governments often include mental health hospitals and outpatient clinics, substance abuse treatment programs, maternal and child health services, and clinics for the homeless. Table 52 shows the distribution of sources of payment for treatment for mental health and addictive disorders in 1996. 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). Care for individuals with mental illness has long been a challenging issue largely due to the historical lack of effective treatment options. Enhanced information technology also promises to aid patients and the public in other ways. Such arrangements have made possible some level of integration of health care and public health services, enhanced information exchange and continuity of care, and allowed public health departments to be reimbursed for the provision of some of the services that are covered by the benefits packages of managed care plans (Martinez and Closter, 1998). Even where electronic medical record systems are being implemented, most of those systems remain proprietary products of individual institutions and health plans that are based on standards of specific vendors. Leigh WA, Lillie-Blanton M, Martinez RM, Collins KS. 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. 1999. Termination of Medi-Cal benefits: a follow-up study one year later, The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 19701998, Determinants of late stage diagnosis of breast and cervical cancer, The late-stage diagnosis of colorectal cancer: demographic and socioeconomic factors, Breast and cervix cancer screening among multiethnic women: role of age, health and source of care, Medicare costs in urban areas and the supply of primary care physicians, A profile of federally funded health centers serving a higher proportion of uninsured patients, Public Health Departments Adapt to Medicaid Managed Care, Local Public Health Practice: Trends & Models, Actual causes of death in the United States, Emergency department overcrowding in Massachusetts : making room in our hospitals, Health Insurance Coverage: Consumer Income, Time trends in late-stage diagnosis of cervical cancer: differences by race/ethnicity and income, Relationships between public and private providers of health care, The Global Burden of Disease. Avoid fragmentation of health plans along socioeconomic lines. Figure 1-1 illustrates that a health care delivery system incorporates four functional componentsfinancing, insurance, delivery, and payment, or the quad-function model. The disruption of traditional community-based care and the displacement of providers who are familiar with the language, culture, and values of ethnic communities create barriers to effective care (Leigh et al., 1999).