4 components of health care delivery system

Studies of the use of preventive services by Hispanics and African Americans find that health insurance is strongly associated with the increased receipt of preventive services (Solis et al., 1990; Mandelblatt et al., 1999; Zambrana et al., 1999; Wagner and Guendelman, 2000; Breen et al., 2001; O'Malley et al., 2001). Focus on Improving Health. the IOM Committee on the Consequences of Uninsurance (IOM, 2001a) found the following: 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 the populations they serve. Figure 1-1 illustrates that a health care delivery system incorporates four functional componentsfinancing, insurance, delivery, and payment, or the quad-function model. Medicaid and Medicare cover 21 percent of treatment, private insurance covers 14 percent, and 10 percent is paid directly by patients as out-of-pocket costs. AAMC (Association of American Medical Colleges). However, the higher rates of uninsurance among racial and ethnic minorities contribute significantly to their reduced overall likelihood of receiving clinical preventive services and to their poorer clinical outcomes (Haas and Adler, 2001). For diseases like tuberculosis and sexually transmitted diseases, public health agencies facilitate active tracking and prophylactic treatment of persons exposed to an infected individual. Draper DA, Hurley RE, Lesser CC, Strunk BC. 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. The report found that aspects of the health care systemits organization, financing, and availability of servicesmay have adverse effects specifically for racial and ethnic minorities. 2002. Rice T, Pourat N, Levan R, Silbert LJ, Brown ER, Gabel J, Kim J, Hunt KA, Hurst KM. 1986. For the patient, the model provides comprehensive care, an emphasis on prevention, and low out-of-pocket costs. Access to care is constrained by limitations on insurance coverage that are greater than those imposed for other diseases. 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. The committee is concerned that the specific types of care that are important for population healthclinical preventive services, mental health care, treatment for substance abuse, and oral health careare less available because of the current organization and financing of health care services. Until recently, the Medicaid waiver program, administered by CMS on behalf of the Secretary of Health and Human Services, did not provide protection of reimbursement rates for clinics within the safety-net system. (Additional discussion of these and other neglected forms of care appears later in this chapter.). A 1998 finalist for the Foster G. McGaw Prize for Excellence in Community Service co-sponsored by AHA, the Franklin Community Health Network (FCHN) in Farmington, Maine, took the lead in developing a coalition and providing seed money to start a Rural Schools Equity Campaign (AHA, 2002). This is because the US health care system is fragmented with many people obtaining and receiving health care through different means. Additionally, Montefiore Medical Center partners with local high schools to develop health care professions education programs intended to create new career options and improve the likelihood inner-city youth will stay in school (Montefiore Medical Center, 2001). (See Chapter 3 for a discussion of the information technology needs of the governmental public health infrastructure.). Ultimately, such systems should also allow the public to contribute and receive information to get the most complete database possible. Total of medical and surgical beds, ICU beds, and special care beds. 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. Henry J. Kaiser Family Foundation and The Harvard Vanguard electronic medical system is queried each night for specific diagnoses assigned during the preceding day in the course of routine care. The Population Health Care Delivery Model. Disease reporting is not complete, however. The convergence and potentially adverse consequences of these new and powerful dynamics lead the committee to be highly concerned about the future viability of the safety net. 2001. In theory, managed care offers the promise of a population-based approach that can emphasize regular preventive care and other services aimed at keeping a defined group as healthy as possible. because the healthcare delivery system in the United States though referred to as a system as a result of its features, components, and services, cannot really be called a system per se. 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). That committee further identified core safety-net providers as having two distinguishing characteristics: (1) by legal mandate or explicitly adopted mission they maintain an open door,' offering access to services to patients regardless of their ability to pay; and (2) a substantial share of their patient mix is uninsured, Medicaid, and other vulnerable patients (IOM, 2000a: 3). The considerably smaller, less well-appreciated public health sector concentrated on populations, prevention, nonbiological determinants of health, and safety-net primary care (Lasker et al., 1997: 274). Many health care settings lack basic computer systems to provide clinical information or support clinical decision making. In its report Barriers to treatment include stigma, lack of available treatment facilities, unwillingness to admit that treatment is needed, and inability to pay for care. Lasker RD, This increase comes from the growth of the older population and the proportion of the overall population with chronic conditions, along with the introduction of new and more expensive drugs, many of which are used to treat chronic conditions. 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). Support the use of interpretation services where community need exists. 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. The health care sector in the United States consists of an array of clinicians, hospitals and other health care facilities, insurance plans, and purchasers of health care services, all operating in various configurations of groups, networks, and independent practices. For children, too, being uninsured tends to reduce access to health care and is associated with poorer health. 1996. Poor oral care can also contribute to oral cancer, and untreated tooth decay can lead to tooth abscess, tooth loss, andin the worst casesserious destruction of the jawbone (Meadows, 1999). 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. Smaller practices have great difficulty in organizing the array of services and support needed to efficiently manage chronic disease. Although safety net providers have proven to be both resilient and resourceful, the committee believes that many providers may be unable to survive the current environment. . 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. Children's Preventive Health Care under Medicaid. Computer-based systems for the entry of physician orders have been found to have sizable benefits in enhancing patient safety (Bates et al., 1998, 2001; Schiff et al., 2000). Phase 1. Payment. 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). Employer acceptance may change in the face of double-digit insurance premium increases. Is managed care leading to consolidation in healthcare markets? Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. Individuals and families living below the poverty level experience more dental decay than higher-income groups, and their cavities are less likely to be treated (GAO, 2000). If the goals of population health are to be realized, the focus must extend beyond the traditional clinical setting to . At present, nine states (California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee) act as a national resource for the surveillance, prevention, and control of emerging infectious diseases (CDC, 2002). Because insurance status affects access to secure and continuous care, it also affects health, leading to an estimated 18,000 premature deaths annually (IOM, 2002a). Although these reductions may have improved the efficiencies of hospitals, they have important implications for the capacity of the health care system to respond to public health emergencies. 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). 3200 Four Components of Health Care Health Systems & the Factors affecting Health Care Delivery Goals of a Consumer Bill of Rights and Responsibilities Abbreviations and computer systems in health care How Social Movements Impact Society Non-profit organization: Bill & Melinda Gates Foundation Marketing Plan Health care delivery systems differ depend- ing on the arrangement of these components. Second, they are the principal providers of specialized services and serve as regional referral centers for smaller towns or cities and rural areas. Coalition members decided to tackle, in order, injuries caused by car accidents, violence, falls, and burns, through 11 initiatives involving more than 80 community organizations and agencies. Disease surveillance and reporting provide a classic exemplar of essential collaboration between the health care system and the governmental public health agencies. With these chronic . 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). 2002. 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. This number represented about 15 percent of the total population of 274 million persons at that time and 17 percent of the population younger than 65 years of age; 10 million of the uninsured are children under the age of 18 (about 14 percent of all children), and about 32 million are adults between the ages of 18 and 65 (about 19 percent of all adults in this age group). The committee took special note of certain shortages of health care professionals, because these shortages are having a significant adverse effect on the quality of health care. What makes up the healthcare system? 2000. Infections in the mouth can enter the bloodstream and affect the functioning of major organs (e.g., bacterial endocarditis, in which infection causes the lining of the heart and the heart valves to become inflamed) (Meadows, 1999). 2002. Boards of Trustees (2002). This oversight is often reflected by health insurance coverage restrictions that exclude oral health care. This fi gure identifi es the relationship between the four major components of the health care delivery system: Payer. We'll create an entirely exclusive & plagiarism-free paper for $13.00 $11.05/page 569 certified experts on site View More 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). The committee discusses the extent of this separation and the particular need for better collaboration, especially in regard to assuring access to health care services, disease surveillance activities, and partnerships toward broader health promotion efforts. Medicare provides coverage to 13.5 percent of the population, whereas Medicaid covers 11.2 percent of the population (Mills, 2002). Collect and report data on health care access and utilization by patients' race, ethnicity, socioeconomic status, and, where possible, primary language. 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). See also pregnancy. Macinko JA, Starfield B, Shi L. [in press]. Many people who are counted as insured have very limited benefits and are exposed to high out-of-pocket expenses or service restrictions. Although this survey serves only as an illustration of what may be possible, several elements appeared supportive of a sustained commitment to efforts at community health improvement. Services, Consumers, Personnel, and Payment Hospitals vary in size, ownership, and types of services. In this section, the committee reviews concerns about the barriers to health care that are raised by the lack of health insurance and by threats to the nation's safety-net providers. According to a report of the Surgeon General, fewer than one in five Medicaid-covered children received a single dental visit in a recent year-long study period (DHHS, 2000b). Implement multidisciplinary treatment and preventive care teams. 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). v Preface The Commonwealth Fund Commission on a High Performance Health System is pleased to present the report, Organizing the U.S. Health Care Delivery System for High Performance, which addresses fragmentation in the U.S. delivery system, a problem that leads to frustrating and dangerous patient What are the two main objectives of a healthcare delivery system? The Internet already offers a wealth of information and access to the most current evidence to help individuals maintain their own health and manage disease. 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. Increasing their numbers and assuring their viability can, to some degree, improve the availability of care. The committee encourages the health care system and policy makers in the public and private sectors to give careful consideration to the interventions that are identified in Unequal Treatment (IOM, 2002b) and aimed at eliminating racial and ethnic disparities in health care (see Box 58). Having a regular source of care improves chances of receiving personal preventive care and screening services and improves the management of chronic disease. There is a significant . The uninsured were less likely to receive health care services, even for serious conditions. Identify a defined population (community) and develop links to that community Assess health status and need, and adjust the volume and types of services provided to respond to the health needs of (more). Better information systems that allow the rapid and continuous exchange of clinical information among health care providers and with public health agencies have the potential to improve disease surveillance as well as aid in clinical decision making while avoiding the use of unnecessary diagnostic tests. Over the same period, out-of-pocket payments for specific types of substance abuse treatment increased (Coffey et al., 2001). The adequacy of hospital capacity cannot be assessed without considering the system inefficiencies that characterize current insurance and care delivery arrangements. According to the American Hospital Association (2001a), the demand for emergency department care increased by 15 percent between 1990 and 1999. This may be because of cost concerns or insurance plan restrictions or simply professional judgment that the test is unnecessary for appropriate clinical care. Integrated Delivery System. Burstin HR, Swartz K, O'Neill AC, Orav EJ, Brennan TA. Information, of course, is the key. Fundamental flaws in the systems that finance, organize, and deliver health care work to undermine the organizational structure necessary to ensure the effective translation of scientific discoveries into routine patient care, and many parts of the health care delivery system are economically vulnerable. Cagney KA, Kerner J. The U.S. health care system is complex, and it is difficult to reduce all of its elements, influences, and decision makers into a simple diagram. 1993. 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. The term "health care organization" is meant to encompass all settings of care in which the diagnostic process occurs, such as integrated care delivery settings, hospitals, clinician practices, retail . 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. 2001. Having any health insurance, even without coverage for any preventive services, increases the probability that an individual will receive appropriate preventive care (Hayward et al., 1988; Woolhandler and Himmelstein, 1988; Hsia et al., 2000). The development of enhanced information technology and its use in hospitals, individual provider practices, and other segments of the health care delivery system are essential for improving the quality of care. Results from the William M. Mercer/Partnership for Prevention Survey of Employer Sponsored Plans, Prevention Priorities: Employers' Guide to the Highest Value Preventive Health Services, Transition Report to the New Administration: Strengthening Our Public Health Defense Against Environmental Threats, Barriers to care among racial/ethnic groups under managed care, Inequality in America: the contribution of health centers in reducing and eliminating disparities in access to care, Changes in insurance coverage and extent of care during the two years after first hospitalization for a psychotic disorder, Demand for health care information prompts mediainstitution alliances, The de facto US mental and addictive disorders service system. Low-income Hispanic children and adults are less likely to be eligible for Medicaid than other groups, so even the limited Medicaid benefits are unlikely to be available to them. 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). When people think about the components of good health, they often forget about the importance of good oral health. 1988. NOTE: VHA = Veterans Health Administration; IHS = Indian Health Service; DOD = Department of Defense; FEHBP = Federal Employees Health Benefits Program. Sentinel networks that specifically link groups of participating health care providers or health care delivery systems to a central data-receiving and -processing center have been particularly helpful in monitoring specific infections or designated classes of infections. It includes pharmaceuticals, biotechnology and diagnostic laboratories. Bates D, Cohen M, Leape LL, Overhage JM, Shabot MM, Seridan T. 2001. Concepts from general systems theory are useful inunderstanding the structure and operation of a nation's health system. Most recipients (87 percent) of specialty treatment for alcohol or drug abuse receive it in outpatient settings (RWJF, 2001), but overall, less than one-fourth of those who need treatment get it. . The link between the availability of primary care and better health is also supported by international evidence, which shows that nations that value primary care are likely to have lower mortality rates (all causes; all causes, premature; and cause specific), even when controlling for macro- and micro-level characteristics (e.g., gross domestic product and per capita income) (Macinko et al., in press). Additionally, the system has continued to undergo continuous changes . Medical professionals such as WHO agree that embracing the 6 components of health will allow patients to lead more complete lives. 2000. Committee on Medicine and Public Health. 2002. Although these various individuals and organizations are generally referred to collectively as "the health care delivery system," the phrase suggests an order, integration, and accountability that do not exist. In particular, managed care rules have changed to allow increased coverage of care provided in emergency departments. IOM (Institute of Medicine). Policies promoting the portability and continuity of personal health information are essential. HELP (Health & Education Leadership for Providence). These expected numbers allow estimates of the probability of observing specific numbers of cases, either overall or in specific census tracts, and the rapid identification of an unusual cluster of events. Lazarus R, Kleinman K, Dashevsky I, Adams C, Kludt P, DeMaria A Jr, Platt R. 2002. The health care delivery system as it exists today cannot deliver those elements. 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 . 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. 308 qualified specialists online. When individuals cannot access mainstream health care services, they often seek care from the so-called safety-net providers. Private insurance is predominantly purchased through employment-based groups and to a lesser extent through individual policies (Mills, 2002). SOURCE: Zuvekas (2001), based on the 1996 Medical Expenditure Panel Survey. Cardiovascular disease and diabetes exemplify the problem. d One of the most striking aspects of Covid-19 is that it often exploits underlying chronic conditions such as diabetes, heart disease, and obesity. Billings and colleagues (1993) demonstrated strong links between hospital admission rates for such conditions and the socioeconomic and insurance status of the population in an area. CMS (2002a); CMS (2002a); CMS (2002c). An estimated 100 million Americans have one or more chronic conditions, and that number is estimated to reach 134 million by 2020 (Pew Environmental Health Commission, 2001). the U.S. Preventive Services Task Force and provide evidence-based coverage of oral health, mental health, and substance abuse treatment services. The operational separation of public health and health care financing programs mirrors the cultural differences that characterize medicine and public health. 1.1.1. Other changes in the health care delivery system also raise concerns about the infectious disease surveillance system. In Providence, Rhode Island, a community partnership of nonprofit and independent hospitals and colleges works to improve children's quality of life by providing school-based health services, innovative and enhanced education through teacher and staff training, and support to improve home environments through housing advocacy (Health & Education Leadership for Providence, 2001; Providence Public School District, 2002). Wagner and colleagues (1996) identified five elements required to improve outcomes for chronically ill patients: Reorganization of practices to meet the needs of patients who require more time, a broad array of resources, and closer follow-up. 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. The committee believes that the effects of these combined forces and dynamics demand the immediate attention of public policy officials. Consumer demands for more choice and greater flexibility are weakening restrictions on access to providers and limitations on services. Medicare excludes coverage of routine dental care, and many state Medicaid programs do not provide dental coverage for eligible children or adults. Chapter 4 provides additional examples of fruitful community partnerships involving the health care sector. When people think about the components of good health, they often forget about the importance of good oral health. Promote the consistency and equity of care through the use of evidence-based guidelines. Strasz M, Allen DJ, Paterson Sandie AK. SOURCE: Adapted from Olson et al. In 1988, about three-quarters of adults with employment-based health insurance had a benefit package that included adult physical examinations. Relative standard error is too large to support reliable estimation. 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. Inequities in health services among insured Americans: do working-age adults have less access to medical care than the elderly? It is the responsibility of the federal government to lead a national effort to examine the options available to achieve stable health care coverage of individuals and families and to assure the implementation of plans to achieve that result. Lurie N, Ward NB, Shapiro MF, Brook RH. Recommendations Concerning Safety-Net Services. Additionally, public funding supports directly delivered health care (through community health centers and other health centers qualified for Medicaid reimbursement) accessed by 11 percent of the nation's uninsured, who constitute 41 percent of patients at such health centers (Markus et al., 2002).

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