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5. The Health Care Delivery System
Pages 212-267

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From page 212...
... report Crossing the Quality Chasm (2001b: 6~: "All health care organizations, professional groups, and private and public purchasers should adopt as their explicit purpose to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States." This chapter addresses the issues of access, managing chronic disease, neglected health care services (i.e., clinical preventive services, oral, and mental health care and substance abuse services) , and the capacity of the health care delivery system to better serve the population in terms of cultural competence, quality, the workforce, financing, information technology, and emergency preparedness.
From page 213...
... Insurance plans and providers scramble to adapt and survive in a rapidly evolving and highly competitive market; and the variations among health insurance plans whether public or private in 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. Because of its history, structure, and particularly the highly competitive market in health services that has evolved since the collapse of health care reform efforts in the early 1990s, the health care delivery system often does not interact effectively with other components of the public health system described in this report, in particular, the governmental public health agencies.
From page 214...
... Although this committee was not constituted to investigate or make recommendations regarding the serious economic and structural problems confronting the health care system in the United States, it concluded that it must examine certain issues having serious implications for the public health system's effectiveness in promoting the nation's health. Drawing heavily on the work of other IOM committees, this chapter examines the influence that health insurance exerts on access to health care and on the range of care available, as well as the shortcomings in the quality of services provided, some of the constraints on the capacity of the health care system to provide high-quality care, and the need for better collaboration within the public health system, especially among governmental public health agencies and the organizations in the personal health care delivery system.
From page 215...
... The fact that more than 41 million people more than 80 percent of whom are members of working families are uninsured is the strongest possible indictment of the nation's health care delivery system. Those without health insurance or without insurance for particular types of services face serious, sometimes insurmountable barriers to necessary and appropriate care.
From page 216...
... When individuals cannot access mainstream health care services, they often seek care from the so-called safety-net providers. These providers include institutions and professionals that by mandate or mission deliver a large amount of care to uninsured and other vulnerable populations.
From page 217...
... Emergency and trauma care were also found to vary for insured and uninsured patients. Uninsured persons with traumatic injuries were less likely to be admitted to the hospital,
From page 218...
... Many people who are counted as insured have very limited benefits and are exposed to high out-of-pocket expenses or service restrictions. Three areas in which benefits are frequently circumscribed under both public and private insurance plans are preventive services, behavioral health care (treatment of mental illness and addictive disorders)
From page 219...
... The organization and delivery of safety-net services vary widely from state to state and community to community (Baxter and Mechanic, 1997~. The safety net consists of public hospital systems; academic health centers; community health centers or clinics funded by federal, state, and local governmental public health agencies (see Chapter 3~; and local health departments themselves (although systematic data on the extent of health department services are lacking)
From page 220...
... 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)
From page 221...
... Clinical Preventive Services The evidence that insurance makes a difference in health outcomes is well documented for preventive, screening, and chronic disease care (IOM, 2002b)
From page 222...
... may account for the fact that managed care plans tend to offer the most comprehensive coverage of clinical preventive services and traditional indemnity plans tend to offer the least comprehensive coverage. Although the trend toward inclusion of clinical preventive services is positive, such benefits are still limited in scope and are not well correlated with evidence regarding the effectiveness of individual services.
From page 223...
... Medicare Coverage of Preventive Services Preventive services are important for older adults, for whom they can reduce premature morbidity and mortality, help preserve function, and enhance quality of life. 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.
From page 224...
... Although cardiovascular disease is the leading cause of death and diabetes is one of the most significant chronic diseases affecting Medicare beneficiaries, physicians cannot screen for lipids disorders or diabetes unless the patient agrees to pay out-of-pocket for the tests. Medicaid Coverage of Preventive Services 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.
From page 225...
... Additionally, those with no insurance all year paid nearly 60 percent of costs out-of-pocket, whereas those with some private insurance paid 40 percent of costs out-of-pocket in 1996 (Zuvekas, 2001~. Adults' use of mental health services in both the general and the specialty mental health sectors correlates highly with health insurance coverage (Cooper-Patrick et al., 1999; Wang et al., 2000; Young et al., 2001)
From page 227...
... The limited and unstable nature of insurance for treatment of mental illness has several implications for governmental public health agencies because the severely mentally ill are likely to end up receiving care in publicly funded safety-net programs (Rabinowitz et al., 2001~. Funding to support the public mental health system comes from reimbursements for
From page 228...
... Treatment for Substance Abuse In the United States, more than 18 million people who use alcohol and nearly 5 million who use illicit drugs need substance abuse treatment (SAMHSA, 2001~. Substance abuse, like mental illness, exacts enormous social costs across all segments of society.
From page 229...
... However, the high out-ofpocket costs faced by individuals who pay for their own treatment discourage many who need care from seeking it. Oral Health Care Like mental illness and addiction disorders, oral health has been neglected in the health care delivery system.
From page 230...
... The forecast for major oral health problems among the nation's fastest-growing population group, Hispanics, is especially alarming. 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.
From page 231...
... Two particular quality problems have special significance in terms of assuring the health of the population: disparities in the quality of care provided to racial and ethnic minorities and inadequate management of chronic diseases. As the American population grows both older and more racially and ethnically diverse and as rates of chronic disease increase, important vuinerabilities in the health care delivery system are compromising individual and population health (Murray and Lopez, 1996; Hetze!
From page 232...
... 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. 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~.
From page 233...
... , effective health care for chronic disease management is a collaborative process, involving the "definition of clinical problems in terms that both patients and providers understand; joint development of a care plan with goals, targets, and implementation strategies; provision of self-management training and support services; and active, sustained follow-up using visits, telephone calls, e-mail, and Web-based monitoring and decision support systems." The current health care system does not meet the challenge of providing clinically appropriate and cost-effective care for the chronically ill. Crossing the Quality Chasm (IOM, 2001b: 28)
From page 234...
... CAPACITY OF THE HEALTH CARE SYSTEM TO SERVE THE POPULATION 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. The relentless focus on controlling costs over the past decade has squeezed a great deal of excess capacity out of the health care system, particularly the hospital system.
From page 235...
... The severe underrepresentation of racial and ethnic minorities in the health professions affects access to care for minority populations, the quality of care they receive, and the level of confidence that minority patients have in the health care system. A consistent body of research indicates that African-American and Hispanic physicians are more likely to provide services in minority and underserved communities and are more likely to treat patients who are poor, Medicaid eligible, and sicker (IOM, 2001c)
From page 236...
... Hospital Nursing Shortage RNs work in a variety of settings, ranging from governmental public health agency clinics to hospitals and nursing homes. The majority, however, work in hospitals, although the proportion dropped from 68 percent in 1968 to 59 percent in 2000 (Spratley et al., 2000~.
From page 237...
... The shortage of RNs poses a serious threat to the health care delivery system, and to hospitals in particular. Hospitals and the Capacity for Emergency Response Hospitals contribute in various ways to assuring the health of the public, particularly by providing acute care services, educating health professionals, serving as a site for research, organizing community health promotion and disease prevention activities, and acting as safety-net providers.
From page 238...
... According to the American Hospital Association (2001a) , the demand for emergency department care increased by 15 percent between 1990 and 1999.
From page 239...
... 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.
From page 240...
... makes clear that the misuse of services also characterizes disease management among insured chronically ill patients. In the early 1990s, managed care became a common feature of the health care delivery system in the United States.
From page 241...
... 2 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. 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.
From page 242...
... (See Chapter 3 for a discussion of the information technology needs of the governmental public health infrastructure.) Crossing the Quality Chasm (IOM, 2001b)
From page 243...
... Systems and protocols for linking health care providers and governmental public health agencies are vital for detecting emerging health threats and supporting appropriate decisions by all parties. The committee cautions, however, that systems dedicated to a single use, such as bioterrorism, will not be optimal; systems designed to be comprehensive and flexible will be of greater overall value.
From page 244...
... . COLLABORATION WITH GOVERNMENTAL PUBLIC HEALTH AGENCIES The activities and interests of the health care delivery system and the governmental public health agencies clearly overlap in certain areas, but there is relatively little collaboration between them.
From page 245...
... The failure to collaborate characterizes not only the interactions between governmental public health agencies and the organizations and individuals involved in the financing and delivery of health care in the private sector but also financing within the federal government. Within the Department of Health and Human Services (DHHS)
From page 246...
... Some provide no personal health care services at all, whereas others provide some assortment of primary health care and safety-net services. In general, however, there has been a decrease in the number of local governmental public health agencies involved in direct service provision.
From page 247...
... 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~. At this time, governmental public health agencies are still called on to play a role in assurance broader than that which may be compatible with their other responsibilities to population health.
From page 248...
... has not been well supported and, as noted earlier, suffers from issues of lack of timeliness and incomplete reporting, as well as complex or unclear reporting procedures and limited feedback from governmental public health agencies on how data are used (Baxter et al., 2000; Stagg Elliott, 2002~. Health care delivery systems may fear that the data will be used to measure performance, and concerns about patient confidentiality can also contribute to a reluctance to report some diagnoses.
From page 249...
... A CDC-funded project of the Massachusetts Department of Public Health and the Harvard Vanguard Medical Associates (a large multispecialty group) offers a glimpse of the benefits to be gained through collaboration between health care delivery systems and governmental public health agencies and specifically through the effective use of medical information systems (Lazarus et al., 2002~.
From page 250...
... serve as a critical interface with governmental public health agencies in several ways. First, as noted earlier, AHCs are an important part of the safety-net system in most urban areas.
From page 251...
... COLLABORATION WITH OTHER PUBLIC HEALTH SYSTEM ACTORS 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. Relationships between the health care sector hospitals, community health centers, and other health care providers and the community are not
From page 252...
... The AHCs surveyed listed several factors that facilitated the development of relationships with communities and community organizations, including the request of the communities themselves and the growing population health orientation of the health care sector. Furthermore, non-academic community health centers also frequently have close ties to their communities, collaborating to assess local health needs, providing needed services, and supporting community efforts with research expertise and technical assistance in planning and evaluation.
From page 253...
... Vignettes drawn from the experience of American Hospital Association NOVA Award recipients illustrate the importance of investing in overall community health (AMA, 2002~. For example, in 1994, Parkland Health and Hospital System in Dallas noted that injury rates in the community were three times the national average and that trauma admissions had jumped 38 percent in one year (53 percent of that care is uncompensated)
From page 254...
... ; · Building an evidence base through evaluation and ongoing measurement of community health indicators; and · Exploring external revenue streams and advocating for changes in current health care financing and funding for such efforts (VHA Health Foundation and HRET, 2000~. Boufford (1999)
From page 255...
... Businesses and employers most commonly interface with the health care sector in purchasing and designing employee health benefits, with goals such as the inclusion of comprehensive preventive health care services. However, there are examples of wide-reaching business-health care linkages, such as the efforts to ensure quality of care and enhanced consumer choice undertaken by the Pacific Business Group on Health (see Chapter 6~.
From page 256...
... With the economic downturn in 2001, the growth in health care spending creates added financial burdens for everyone, including individuals seeking care or insurance coverage, employers offering health insurance benefits, and governments at the federal, state, and local levels managing publicly funded insurance programs (Fronstin, 2002; Trude et al., 2002~. Substantial increases in health insurance premiums are a clear indication of these economic stresses.
From page 257...
... These circumstances force public health departments to provide personal health care services instead of using their resources and population-level approaches to guide and support community efforts to change the conditions for health. Closer collaboration and integration between governmental public health agencies and the health care delivery system may enhance the capacities of both to improve population health and may support the efforts of other public health system actors.
From page 258...
... Chicago, IL: Hospital Research and Education Trust, American Hospital Association. Bates D, Cohen M, Leape LL, Overhage JM, Shabot MM, Seridan T
From page 259...
... 1998. Use of clinical preventive services by adults aged <65 years enrolled in healthmaintenance organizations United States, 1996.
From page 260...
... Rockville, MD: Substance Abuse and Mental Health Administration, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services.
From page 261...
... , Part B (Medical Insurance) , including Preventive Services.
From page 262...
... 2000. Grant results report: assessing insurance coverage of preventive services by private employers.
From page 263...
... 1998. Public Health Departments Adapt to Medicaid Managed Care.
From page 264...
... 2001. Changes in insurance coverage and extent of care during the two years after first hospitalization for a psychotic disorder.
From page 265...
... Schauffler HH, Miller LS.2000. The direct and indirect effects of cost-sharing on the use of preventive services.
From page 266...
... 2000. Sustaining community health: the experience of health care system leaders.
From page 267...
... Health Affairs 20(2)


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