As a result of decreasing demand for hospital services and a changing financial environment, hospitals in many parts of the country reduced the number of patient beds, eliminated certain services, or even closed (McManus, 2001). Robert Wood Johnson Foundation (RWJF). Federal and state policy makers should explicitly take into account and address the full impact (both intended and unintended) of changes in Medicaid policies on the viability of safety-net providers and (more). . Second, they are the principal providers of specialized services and serve as regional referral centers for smaller towns or cities and rural areas. Better information technology can also support patients and family caregivers in crucial health decisions, strengthen both personal and population-based prevention efforts, and enhance participation in and coordination with public health activities. If the goals of population health are to be realized, the focus must extend beyond the traditional clinical setting to . The cost to society is also high, with indirect costs from lost productivity for affected individuals and their caretakers estimated at $79 billion in 1990, the last year for which estimates are available (Rice and Miller, 1996). Only 25 percent of people who have a mental disorder obtain diagnosis and treatment from the health care system, in contrast to 60 to 80 percent of those with heart disease (DHHS, 2000a). Four Components of Health Care: H.R. Nearly 3 out of every 10 Americans, more than 70 million people, lacked health insurance for at least a month over a 36-month period. Avoid fragmentation of health plans along socioeconomic lines. However, reimbursement policies for primary care do not support the services necessary to provide evidence-based care for depression (Wells et al., 2000; Schoenbaum et al., 2001). Medicare provides coverage to 13.5 percent of the population, whereas Medicaid covers 11.2 percent of the population (Mills, 2002). In addition, the authority of state health departments in quality monitoring, licensure, and rate setting can cause serious tensions between them and health care organizations. 1997. Ensure that services are cost- effective and meet established standards of quality. All federal programs and policies targeted to support the safety net and the populations it serves should be reviewed for their effectiveness in meeting the needs of the uninsured. Within the direct care system, each military branch is responsible for managing its MTFs and other activities. org/about/community/services/, www.nasbo.org/Publications/PDFs/medicaid2003. Lurie N, Ward NB, Shapiro MF, Brook RH. Late-stage diagnosis of breast cancer in women of lower socioeconomic status: public health implications, Primary care physicians and specialists as personal physicians. For information technology to transform the health sector as it has banking and other forms of commerce that depend on the accurate, secure exchange of large amounts of information, action must be taken at the national level to develop the National Health Information Infrastructure (NHII) (NRC, 2000). Delivery System As illustrated in Figure 1-1, a health care de- livery system incorporates four functional componentsfinancing, insurance, delivery, and payment thatthat are necessary for the delivery of health services. Only a small fraction of physicians offer e-mail interaction (13 percent, in a 2001 poll), a simple and convenient tool for efficient communication with their patients (Harris Interactive, 2001). Private insurance is predominantly purchased through employment-based groups and to a lesser extent through individual policies (Mills, 2002). Policies promoting the portability and continuity of personal health information are essential. A recent study of changes in the capacities and roles of local health departments as safety-net providers found, however, that more than a quarter of the health departments surveyed were the sole safety-net providers in their jurisdictions and that this was more likely to be the case in smaller jurisdictions (Keane et al., 2001). 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. The shortage of RNs poses a serious threat to the health care delivery system, and to hospitals in particular. Effective surveillance requires timely, accurate, and complete reports from health care providers. Safety-net providers are also more likely to offer outreach and enabling services (e.g., transportation and child care) to help overcome barriers that may not be directly related to the health care system itself. Reports of sentinel events have proved useful for the monitoring of many diseases, but such reports may be serendipitous and generated because of close clustering, unusual morbidity and mortality, novel clinical features, or the chance availability of medical expertise. A survey of 69 hospitals belonging to the National Association of Public Hospitals indicated that in 1997, public hospitals provided more than 23 percent of the nation's uncompensated hospital care (measured as the sum of bad debt and charity care) (IOM, 2000a). The fact that more than 41 million peoplemore than 80 percent of whom are members of working familiesare uninsured is the strongest possible indictment of the nation's health care delivery system. This change has been a challenge to the multiple roles of public health departments as community-based primary health care providers, safety-net providers, and providers of population-based or traditional public health services. Is managed care leading to consolidation in healthcare markets? This would not be a problem if health care systems used currently available information technologies, including electronic medical records and internal disease surveillance systems. Mexican-American adults and children are more likely to have untreated decayed teeth than any other population group. Unlike forms of treatment that are incorporated into the payment system on a relatively routine basis as they come into general use, preventive services are subject to a greater degree of scrutiny and a demand for a higher level of effectiveness, and there is no routine process for making such assessments. Additionally, disabling chronic conditions affect all age groups, but about two-thirds are found in individuals over age 65. For example, Hadley and colleagues (1991) found that uninsured adult hospital inpatients had a significantly higher risk of dying in the hospital than their privately insured counterparts. Mark DH, Gottlieb MS, Zellner BB, Chetty VK, Midtling JE. . AAMC (Association of American Medical Colleges). 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. . (Eds.). The U.S. Preventive Services Task Force (USPSTF), a panel of experts convened by the U.S. Public Health Service, has endorsed a core set of clinical preventive services for asymptomatic individuals with no known risk factors. 1991. Some provide no personal health care services at all, whereas others provide some assortment of primary health care and safety-net services. AHA (American Hospital Association). In 1990, the Health Care Financing Administration established a participant rate goal of 80 percent, to be achieved by fiscal year 1995. 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), and health insurance coverage specifically for mental health services is associated with an increased likelihood of receiving such care (Wang et al., 2000; Young et al., 2000). Yet the public and many elected officials seem almost willfully ignorant of the magnitude, persistence, and implications of this problem. As detailed in Chapter 1, the result is that individuals over age 65 constitute an increasingly large proportion of the U.S. population13 percent today, increasing to 20 percent over the next decade. This may reflect the limited range of benefits covered by Medicare, as well as other barriers such as copayments, participants' unfamiliarity with the services, or the failure of physicians to recommend them. 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). Smith et al. America's Children: Health Insurance and Access to Care, America's Health Care Safety Net: Intact but Endangered, To Err Is Human: Building a Safer Health System, Coverage Matters: Insurance and Health Care, Crossing the Quality Chasm: A New Health System for the 21st Century, The Right Thing to Do, The Smart Thing to Do: Enhancing Diversity in Health Professions, Care Without Coverage: Too Little, Too Late, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health, Setting the Course: A Strategic Vision for Immunization Part 1: Summary of the Chicago Workshop, Stabilizing the Rural Health Infrastructure, Attitudes towards, and utility of, an integrated medical-dental patient-held record in primary care, Gaining and losing health insurance: strengthening the evidence for effects on access to care and health outcomes, Local health departments' changing role in provision and assurance of safety-net services, Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Henry J. Kaiser Family Foundation and The type of health plan is the most important predictor of coverage (RWJF, 2001). In addition, segmentation of health care plans was found to play a significant role in producing poorer care for racial and ethnic minorities because they are more likely than whites to be enrolled in lower-end health plans (IOM, 2002b). Some studies indicate that, on average, minority physicians treat four to five times more minority patients than do white physicians, and studies of recent minority medical school graduates indicate that they have a greater preference to serve in minority and underserved areas. The adequacy of hospital capacity cannot be assessed without considering the system inefficiencies that characterize current insurance and care delivery arrangements. Patients regularly spent significant portions of their admission on gurneys in a hallway. Financing, insurance, delivery and reimbursement are the four functional components make up the quad-function model. We call them the "five S's" and use them to guide our work every day. The level of use of preventive services among older adults has been relatively low (CDC, 1998). The ability of academic medicine to evolve into a broader mission will depend on changes in payment systems that may be difficult to achieve and on internal changes within AHCs that may be equally difficult. 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. Figure 1-1 illustrates that a health care delivery system incorporates four functional componentsfinancing, insurance, delivery, and payment, or the quad-function model. The overcrowding was severe, resulting in delays in testing and treatment that compromised patient outcomes. It includes pharmaceuticals, biotechnology and diagnostic laboratories. Solis JM, Marks G, Garcia M, Shelton D. 1990. Concierge medicine, according to Healthline, is a new healtchare delivery system that's quickly gaining traction. O'Malley AS, Mandelblatt J, Gold K, A mechanism for providing services that meet the health-related needs of individuals. Boufford (1999) has suggested a Community Health Improvement Strategy that identifies a number of steps that provider organizations can take in such community-based efforts (see Box 59). The Harvard Vanguard electronic medical system is queried each night for specific diagnoses assigned during the preceding day in the course of routine care. Many hospitals and health care systems have seen the value of going beyond the needs of the individuals who enter the health care system to engage in broader community health action, even within the constraints of the current environment. NASBO (National Association of State Budget Officials). Hayward RA, Shapiro MF, Freeman HE, Corey CR. Oral diseases are causally related to a range of significant health problems and chronic diseases, as well as individuals' ability to succeed in school, work, and the community (DHHS, 2000b). Among physicians, about 3 percent are African American, 2.2 percent are Hispanic, and 3.6 percent are Asian (AAMC, 2000). Care for individuals with mental illness has long been a challenging issue largely due to the historical lack of effective treatment options. Of the 22.9 million children eligible for EPSDT in 1996, only 37 percent received a medical screening procedure through the program (Olson, 1998) (see Box 55). Inequities in health services among insured Americans: do working-age adults have less access to medical care than the elderly? Such plans are characterized by higher per capita resource constraints and stricter limits on covered services (Phillips et al., 2000). The current health care system does not meet the challenge of providing clinically appropriate and cost-effective care for the chronically ill. HMO. However, when fewer diagnostic tests are performed for self-limiting illnesses like diarrhea, there may be delays in recognizing a disease outbreak. 1994. States are experiencing serious pressures from growth in Medicaid spending, which increased by about 13 percent from 2001 to 2002, following a 10.6 percent increase in 2001 (NASBO, 2002a). The 1998 IOM report America's Children: Health Insurance and Access to Care found that uninsured children are more likely to be sick as newborns, less likely to be immunized as preschoolers, less likely to receive medical treatment when they are injured, and less likely to receive treatment for illness such as acute or recurrent ear infections, asthma and tooth decay (IOM, 1998: 3). 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). The Future of the Public's Health in the 21st Century. 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. 2001. Like mental illness and addiction disorders, oral health has been neglected in the health care delivery system. White paper, Emergency department overcrowding: an action plan, Improving chronic illness care: translating evidence into action, Health care utilization among Hispanics: findings from the 1994 Minority Health Survey, Recent care of common mental disorders in the United States, Geographic variation in expenditures for physician' services in the United States, Stage at diagnosis in breast cancer: race and socioeconomic factors, Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial, Free care: a quantitative analysis of health and cost effects of a national health program for the United States, Routine outcome monitoring in a public mental health system: the impact of patients who leave care, The quality of care for depressive and anxiety disorders in the United States, Use of cancer screening practices by Hispanic women: analyses by subgroup. The result of this interplay is that many governmental public health agencies have found themselves in a strained relationship with managed care organizations: on the one hand, encouraging their active partnership in an intersectoral public health system and, on the other, competing with them for revenues (Lumpkin et al., 1998). IOM (Institute of Medicine). In other words, to deliver true evidence-based care, evidence-based management is necessary to support it. The health care delivery system as it exists today cannot deliver those elements. For example, the California Public Employees' Retirement System, which is the nation's second largest public purchaser of employee health benefits, recently announced that health insurance premiums would increase by 25 percent (Connoly, 2002). Heffler S, Smith S, Won G, Clemens MK, Keehan S, Zezza M. 2002. 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. The National Bureau of Economic Research (NBER) Center of Excellence defines a health system as a group of healthcare organizations (e.g., physician practices, hospitals, skilled nursing facilities) that are jointly owned or managed (foundation models are considered a form of joint management). American fascination with technology, science, and medical interventions and a relatively poor understanding of the determinants of health (see Chapter 2) or of the workings of the governmental public health agencies also contribute to the lower status, fewer resources, and limited influence of public health.

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