for only $13.00 $11.05/page. There is a significant . 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. The rapid development and widespread implementation of an extensive set of standards for technology and information exchange among providers, governmental public health agencies, and individuals are critical. Despite this, 28 percent of local public health departments report that they are the sole safety-net providers in their communities (Keane et al., 2001). Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. These providers include institutions and professionals that by mandate or mission deliver a large amount of care to uninsured and other vulnerable populations. 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. Here, we'll discuss seven common models: HMO, PPO, POS, EPO, PFFS, SNP and ACO and examine the differences between each one. 1998. Governmental public health agencies also depend on astute clinicians to inform them of sentinel cases of recognized diseases that represent a special threat to the public's health and of unusual cases, sometimes without a confirmed diagnosis, that may represent a newly emerging infection, such as Legionnaires' disease or West Nile virus in North America. 1995. 2000. Regier DA, Narrow W, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. 2001. Cooper-Patrick L, Gallo JJ, Powe NR, Steinwachs DM, Eaton WW, Ford DE. 1991. 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. 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. 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. (See Chapter 3 for a discussion of the information technology needs of the governmental public health infrastructure.). Research consistently finds that persons without insurance are less likely to have any physician visits within a year, have fewer visits annually, and are less likely to have a regular source of care (15 percent of uninsured children do not have a regular provider, whereas just 5 percent of children with Medicaid do not have a regular provider), and uninsured adults are more than three times as likely to lack a regular source of care. For example, toxic or infectious exposures could be tracked more easily if the characteristics of every patient encounter were integrated into one system and if everyone had unimpeded access to systems of care that could generate such data. 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. In 1988, about three-quarters of adults with employment-based health insurance had a benefit package that included adult physical examinations. Medical professionals such as WHO agree that embracing the 6 components of health will allow patients to lead more complete lives. But how is organized in different countries? Such a system can help realize the public interest related to quality improvement in health care and to disease prevention and health promotion for the population as a whole. Many hospitals participate in broad community-based efforts to achieve some of the conditions necessary for health, for instance, collaborating with community development corporations to contribute financial, human, and technical resources (U.S. Department of Housing and Urban Development, 2002). 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. As of fiscal year 1996, only nine states reported meeting or exceeding the federally established goal. Although evidence has not established that increasing the numbers of minority physicians or improving cultural competence per se influences patient outcomes, existing research supports clear policies to increase the proportion of medical students drawn from minority groups. The United States health care delivery system is based on the quad-function model, which consists of four components that are categorized into financing, insurance, delivery and payment. It is unclear how the types of delivery systems in which PCMHs operate differentially impact outcomes. 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. 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. In 2000, 9 percent of physicians and 12.3 percent of RNs were from racial and ethnic minority groups (AAMC, 2000). 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). As patterns of health care delivery change, old reporting systems are undermined, but the opportunities offered by new types of care systems and technologies have not been realized. This fi gure identifi es the relationship between the four major components of the health care delivery system: Payer Providers, Regulators, and Supplies. False Academic health centers (AHCs) serve as a critical interface with governmental public health agencies in several ways. 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). Delivery of high-quality care to chronically ill patients is especially challenging in a decentralized and fragmented system, characterized by small practices (AMA, 1998). Some provide no personal health care services at all, whereas others provide some assortment of primary health care and safety-net services. 1.1.1. Macinko JA, Starfield B, Shi L. [in press]. In addition, spending for hospital services increased by 5.1 percent between 1999 and 2000, reaching $412 billion, and the cost of nursing home and home health care increased by 3.3 percent (Levit et al., 2002). Within the Department of Health and Human Services (DHHS), the Centers for Medicare and Medicaid Services (CMS) administer the two public insurance programs with little interaction or joint planning with agencies of the U.S. Public Health Service (PHS). The health care and governmental public health sectors are also very unequal in terms of their resources, prestige, and influence on public policy. Learn more. Additionally, the system has continued to undergo continuous changes . The emergency departments of hospitals in many areas of New York City routinely operated at 100 percent capacity (Brewster et al., 2001). Department of Defense (2002). Health care is a priority and source of concern worldwide. With revenues increasing by only about 5 percent in the same period, Medicaid now accounts for more than 20 percent of total state spending (NASBO, 2002b). Clinical preventive services are the medical procedures, tests or counseling that health professionals deliver in a clinical setting to prevent disease and promote health, as opposed to interventions that respond to patient symptoms or complaints (Partnership for Prevention, 1999: 3). 2001. Exhibit 1 Definitions of intervention components for 43 Health Care Innovation Award . Access to care for the insured can also be affected by requirements for cost sharing and copayments. Oral Health as a Component of Total Health. Health care delivery systems differ depend- ing on the arrangement of these components. The difficulty of reporting in a busy practice is also a barrier. The Future of the Public's Health in the 21st Century. As with other types of health services, insurance is a strong predictor of access to and use of dental services, and minorities and low-income populations are much less likely to have dental insurance or to receive dental care. 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), and oral health care. True Which type of hospital earns a profit from the services that are provided? 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. Mandelblatt JS, Gold K, O'Malley AS, Taylor K, Cagney K, Hopkins JS, Kerner J. 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. Access to care is constrained by limitations on insurance coverage that are greater than those imposed for other diseases. A follow-up analysis found the situation to be growing worse for low-income populations, as economic pressures, including lower reimbursements rates, higher practice costs, and limitations on payment for diagnostic tests, squeeze providers who have historically delivered care to academic health centers' low-income populations (Billings et al., 1996). Payment & Delivery Models. Key Indicators for Policy, Early and periodic screening, diagnosis and treatment and managed care, Prescribing potassium despite hyperkalemia: medication errors uncovered by linking laboratory and pharmacy information systems, Uninsured and unstably insured: the importance of continuous insurance coverage, Cost-effectiveness of practice-initiated quality improvement for depression, Best clinical practice: guidelines for managing major depression in primary care, Case studies: Montefiore Medical Center Loan, Income inequality, primary care, and health indicators, Medicaid spending growth: results from a 2002 Survey, The direct and indirect effects of cost-sharing on the use of preventive services, Acculturation, access to care, and use of preventive services by Hispanics: findings from NHANES, 19821984, The Registered Nurse Population. In many cases, funds were no longer available for population-based essential public health services or had to be diverted to the more visibly urgent need of keeping clinics and hospitals open (CDC, 1997). (IOM, 2000a: 206). Lurie N, Ward NB, Shapiro MF, Gallego C, Vaghaiwalla R, Brook RH. Yet the public and many elected officials seem almost willfully ignorant of the magnitude, persistence, and implications of this problem. Lurie N, Ward NB, Shapiro MF, Brook RH. As with other forms of safety-net care, the urgency of providing treatment to the severely mentally ill erodes funds available for prevention purposes. Cardiovascular disease and diabetes exemplify the problem. Figure 1-1 illustrates that a health care delivery system incorporates four functional componentsfinancing, insurance, delivery, and payment, or the quad-function model. 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). Protection against specific illnesses. Montefiore Medical Center in the Bronx, New York, for example, has partnered with a local nonprofit organization to develop low- and moderate-income housing and to establish a neighborhood kindergarten (Seedco and N-PAC, 2002). 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. Financing, insurance, delivery and reimbursement are the four functional components make up the quad-function model. . Barriers to and Facilitators of Digital Health Among Culturally and Linguistically Diverse Populations: Qualitative Systematic Review Barriers to and Facilitators of Digital Health Among Culturally and Linguistically Diverse Populations: Qualitative Systematic Review Loosely affiliated physician networks have no ability to identify their populations and develop programs specifically based on the epidemiology of the defined group. Apply the same managed care protections to publicly funded health maintenance organization (HMO) enrollees that apply to private HMO enrollees. Over the same period, medical and surgical bed capacities were reduced by 17.7 percent, ICU bed capacities were reduced by 2.8 percent, and specialty bed (including burn bed) capacities were reduced by 3.4 percent. Young AS, Klap R, Sherbourne CD, Wells KB. Denver Health, in Colorado, provides an intriguing example of a hybrid, integrated publicprivate health system (Mays et al., 2000). States are largely . 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). 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). So far, however, adoption of even common and less costly information technologies has been limited. The recent trend among universities to assess their level of involvement in their communities and to develop programs focused on service learning, and such public service oriented academic work includes AHCs. SOURCE: Brewster et al. 1999. These benefits are most easily achieved under a fully capitated, group practice model: patients enroll with a health care organization that is paid a certain amount per member per month to provide all necessary or indicated services to the enrolled population, and physicians are paid a monthly fee or are salaried, which separates payment from the provision of individual services. 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. 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. In general, however, there has been a decrease in the number of local governmental public health agencies involved in direct service provision. Barriers to treatment include stigma, lack of available treatment facilities, unwillingness to admit that treatment is needed, and inability to pay for care. Schoenbaum M, Untzer J, Sherbourne C, Duan N, Rubinstein LV, Miranda J, Carney MF, Wells K. 2001. 2001. For these reasons, oral health must recognized as an important component of assuring individual and population health. U.S. Department of Housing and Urban Development. 4 components . 1995. Distribution (percent) of Sources of Payment for Mental Health/Substance Abuse Treatment, by Type of Use, 1996. Includes common inpatient and outpatient services. 2001. HCFA (Health Care Financing Administration). For example, the Substance Abuse and Mental Health Services Administration, a PHS agency, administers block grants to states to augment funding for mental health and substance abuse programs, neither of which is well supported under Medicaid. (Eds.). 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). What are the 4 healthcare delivery system components? 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). 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). The adequacy of hospital capacity cannot be assessed without considering the system inefficiencies that characterize current insurance and care delivery arrangements. 1996. However, this valuable tool 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). Committee on Medicine and Public Health. More than 90 percent of systemic diseases have oral manifestations. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Teutsch SM, editor; , Churchill RE, editor. Lasker and colleagues observed, [t]he dominant, highly respected medical sector focused on individual patients, emphasizing technologically sophisticated diagnosis and treatment and biological mechanisms of disease. Available in most communities. This rule reduced the cost of health insurance coverage. Insurance policies held by many individuals constrain the use of substance abuse services by the exclusion of benefits for such services and by the use of annual and lifetime limits on benefits and other controls on service utilization. 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. This loss of trust in the idea of managed care is also the loss of a great opportunity to improve quality and restrain costs. 2000. 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. Numerous studies, starting with the RAND Health Insurance Experiment, show that copayments also reduce the use of preventive and primary care services by the poor, although not by higher-income groups (Solanki et al., 2000). According to the American Hospital Association (2001a), the demand for emergency department care increased by 15 percent between 1990 and 1999. 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. the IOM Committee on the Consequences of Uninsurance (IOM, 2001a) found the following: Forty-two million people in the United States lacked health insurance coverage in 1999 (Mills, 2000). Increase the proportion of underrepresented U.S. racial and ethnic minorities among health professionals. 1998. 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. Strasz M, Allen DJ, Paterson Sandie AK. GAO (2001b). Personalized systems for comprehensive home care may improve outcomes and reduce costs. What are some delivery systems? 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 Three levels of Health Care Primary Secondary Tertiary Primary Care Goal: To decrease the risk to a client (individual or community) of disease or dysfunction. Hayward RA, Shapiro MF, Freeman HE, Corey CR. 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. The four basic functional components of the US healthcare delivery system are as follows: Financing. 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). 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. Contrary to popular belief, recent immigrants accounted for a relatively small proportion of the uninsured (less than one in five). 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. Ultimately, such systems should also allow the public to contribute and receive information to get the most complete database possible. That report emphasized that untreated health problems can affect children's physical and emotional growth, development, and overall health and well-being. Office of the President of the United States. It includes pharmaceuticals, biotechnology and diagnostic laboratories. Data for children are less reliable, but the overall prevalence of mental disorders is also estimated to be about 20 percent (DHHS, 1999). Young AS, Grusky O, Jordan D, Belin TR. 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. 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). 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). Adults without health insurance are far more likely to go without health care that they believe they need than are adults with health insurance of any kind (Lurie et al., 1984, 1986; Berk and Schur, 1998; Burstin et al., 1998; Baker et al., 2000; Kasper et al., 2000; Schoen and DesRoches, 2000). Washington (DC): National Academies Press (US); 2002. (2001), citing the American Hospital Association (2001a). The importance of counseling and behavioral interventions is evident, given the influence on health of factors such as tobacco, alcohol, and illicit drug use; unsafe sexual behavior; and lack of exercise and poor diets. Other types of public health surveillance activities, such as registries for cancer cases and for childhood immunizations, also depend on reporting from the health care system. For convenience, however, the committee uses the common terminology of health care delivery system. SOURCE: Zuvekas (2001), based on the 1996 Medical Expenditure Panel Survey. 2000. Structure payment systems to ensure an adequate supply of services to minority patients and limit provider incentives that may promote disparities. d Good primary care assures continuity for the patient across levels of care, comprehensiveness of services according to the level of health or illness, and better coordination of these services over time (Starfield, 1998). 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. Adults with either no insurance coverage or coverage that excludes or limits extended treatment of mental illness receive less appropriate care and may experience delays in receiving services until they gain public insurance (Rabinowitz et al., 2001). Ready access to necessary clinical expertise. 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. 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). Focus on Improving Health. Fragmentation of health plans along socioeconomic lines engenders different clinical cultures, with different practice norms (Bloche, 2001). The value of this type of real-time monitoring of unusual disease outbreaks is obvious for early identification of bioterrorism attacks as well as for improvements in clinical care and population health. 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. These legitimate issues are slowly being addressed in policy and practice, but there is a long way to go if this form of communication is to achieve its potential for improving interactions between patients and providers. Schulberg H, Katon W, Simon G, Rush AJ. Leigh WA, Lillie-Blanton M, Martinez RM, Collins KS. Lumpkin JR, Landrum LB, Oldfield A, Kimel P, Jones MC, Moody CM, and Turnock BJ. A sophisticated health information infrastructure is also important to support public health monitoring and disease surveillance activities. 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). 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. The patient-centered medical home (PCMH) model is one such model that aims to deliver coordinated, accessible healthcare to improve outcomes and decrease costs.
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