Healthcare Delivery in US: Historical & Policy Perspectives PDF

Topic # 1: Healthcare delivery in America: Historical & Policy Perspectives ❑ Learning Objectives ✓ Explain paradoxes of the U.S. healthcare system ✓ Explain health conditions in 18th- & 19th-century America in relation to disease patterns & causation theories ✓ Explain types of health practices &...

Topic # 1: Healthcare delivery in America: Historical & Policy Perspectives ❑ Learning Objectives ✓ Explain paradoxes of the U.S. healthcare system ✓ Explain health conditions in 18th- & 19th-century America in relation to disease patterns & causation theories ✓ Explain types of health practices & practitioners & factors explaining access to health care in 19th-century America ✓ Explain the various roles of government in healthcare delivery in 18th- & 19th- century America ✓ Explain the differences between orthodox & sectarian practitioners & their patients in relation to their perspectives on therapeutics & the delivery of health care ✓ Explain changes in the character, organization, & purposes of hospitals as health delivery sites from the early 19th century through the early 21st century ✓ Describe reforms in medical education at the turn of the 20th century & the consequences of the Flexner report of 1910 ✓ Identify the golden age of medicine & describe what replaced it in the late 20th & early 21st centuries 1 ❑ Learning Objectives ✓ Explain the ways in which medicine & pharmacy pursued professionalization in the late 19th & 20th centuries & how these professions define themselves in the 21st century ✓ Explain how the factors of public health, lifestyle (diet, housing, personal hygiene), & medical practice influenced the decline of infectious diseases & increase in life expectancy at the turn of the 20th century ✓ Discuss the occurrences of infectious & chronic diseases in the 21st century ✓ Discuss the types of government policy that affected healthcare delivery in the 20th & early 21st centuries, particularly in relation to the implementation of public & private health insurance ✓ Discuss the implementation of Medicare & Medicaid in the 1960s, the 1973 Health Maintenance Organization Act, the 1996 Health Insurance Portability & Accountability Act, the 1997 Children’s Health Insurance Program, & the 2010 Patient Protection & Affordable Care Act ✓ Explain the benefits & costs of the Medicare Part D Drug Plan ✓ Explain problems associated with incremental healthcare reform ✓ Understand the major components & the significance of the Patient Protection & Affordable Care Act 2 Paradoxes of the U.S. Health Care System ❑ Highest health care standards ✓ Professional & facility licensures ✓ Professional & facility certifications ✓ Drug & medical device testing ❑ Most advanced technology available ❑ Highest expenditure per capita ✓ Approximately 17% of GDP; ✓ U. S. spending surpasses all other countries ❑However… ✓ Fragmentation of health care regulation, financing, & delivery ✓ Very high rate of medical errors (44-98K deaths/yr) ✓ Socioeconomic & racial disparities in outcomes ✓ Not everyone with adequate health insurance 3  An Enormous Industry ❑ U.S. HC: ✓ $ 3 trillion; 16 M+ workers; 11% of employment; 17%+ of GDP ✓ World’s 5th largest “economy” 2nd only to Germany & larger than total economy of UK ✓ Thousands of medical practices, provider organizations, manufacturers, suppliers & insurers System Complexity ❑ A vast array of “players” & “payers” ✓ Mosaic of business relationships range from individual “MD-patient” to multi- billion dollar hospital, HC & insurance systems ✓ Public (govt) & private payment sources with differing rules, regs ✓ Poorly aligned infrastructure, medical specialization result in a confusing labyrinth for patients & providers 4  Enduring Challenges ❑ Size & complexity contribute to problems of: ✓ Limited access, inconsistent quality, high costs ✓ Unnecessary & wasteful service duplications ❑ How to make finest technical medical capabilities available & accessible to pop in effective & efficient ways? Policy vs. Market-driven Attempts to “Reform” the System: ❑ Problems recognized by nation’s medical & political leaders: ✓ legislative proposals for comprehensive reform by eight Presidents ❑ Policy-driven reform failed repeatedly while “market” has driven consolidations to achieve higher quality, effectiveness, lower costs. ✓ Emerging power of consumer demands 5 Health Values, Therapeutics, & Practitioners ❑ In 19th-century America, most health practitioners (as well as the public) believed in the 2nd-century physician Galen’s premise of humoralism regarding health & the body as opposed to the new “germ theory” of disease. ✓ Humoralism – the body is an “interconnected whole” with a natural balance ❖ On Galen’s humoralism: o “(E)very part of the body was related inevitably & inextricably with every other. In health the body’s system was in balance; in disease, the body lost its balance & suffered disequilibrium. If health practitioners were to treat effectively, they needed the knowledge of individual patients & the body’s system of ‘intake & outgo.’” Charles Rosenberg in The Therapeutic Revolution (1985) ❑ And on the use of drugs: ✓ “Drugs had to be seen as adjusting the body’s internal equilibrium; in addition, the drug’s action had, if possible, to alter these visible products of the body’s otherwise inscrutable internal state.” Charles Rosenberg in The Therapeutic Revolution (1985) 6 ❑ 2 Types of Practitioners 1: Orthodox physicians (a.k.a. allopathic or regulars) ✓ Some medical education or apprenticeship ✓ “Heroic” medicine (active role) ❖ Mostly used depletive measures (drugs or procedures), which caused a visible change in secretions & excretions. ❖ Also strengthening measures (tonics & astringents) more often used by the lay public 2: Sectarians (a.k.a. irregulars) ✓ Alternative practices (homeopathy, folk medicines, “cure establishments”) ✓ No formal training ✓ Orthodox physicians & sectarian practitioners usually required payment at the time a service was provided (i.e. fee-for-service), frequently in the home. ✓ Many Americans, especially of the lower economic class, first treated illness by home remedies or low-cost alternative concoctions to avoid fee-for-service. ✓ Services in physicians’ offices, drugstores, & “cure establishments” were mainly sought by middle & upper classes. 7 ❑ 19th to 21st Centuries ✓ commercial manufacture of medicines in the 19th-century started to change the functions of practitioners from making home remedies to prescribing compounds & proprietary preparations (“patent medicines”). ✓ Physicians dispensed proprietary medicines from their office, & pharmacists opened stores, which sold commercial preparations as well as their own or physicians’ concoctions. ✓ latter half of the 19th-century saw the rise of patent medicines advertised in newspapers & available in pharmacies, which became the retailer of choice for prepared drugs. ✓ Around the turn of the century, reformers warned about the safety & fraudulent claims of patent medicines (“quackery”). ✓ Pure Food & Drug Act of 1906 at least addressed accurate labeling. 8 ❑ Hospitals ✓ Early 19th-century hospitals had origins in the almshouse (poor) & pesthouse (isolation). ✓ Early 20th century physicians accepted the germ theory of disease, which led to hospitals: ❖ Improving aseptic/antiseptic & surgical techniques ❖ Improving technology (anesthesia, X-rays) ✓ U.S. hospitals grew in number from 100 to more than 6000 ❖ General hospitals ❖ Specialty hospitals (e.g. mental, children’s, TB) ❖ Sponsored by religious, ethnic, & physician groups et.al.) 9 ❑ Federal Funding ✓ National Hospital Survey & Construction Act of 1946 (a.k.a. Hill-Burton Act) for planning & construction of new hospitals & public health centers. ✓ National Institutes of Health for medical research (NIH) ✓ Medicare & medical education ❑ Hospitals in 20th & 21st Century ✓ Medicare & Medicaid Impact Hospitals & Service Role ✓ Managed Care, Consumerism, & Social Mission of Hospitals Experience Conflicts ✓ 2001 Crossing the Quality Chasm & Patient-Centered Care Goals 10 ❑ Medicine ✓ 1910: Medical Education in USA & Canada (a.k.a. “The Flexner Report”) ❖ Re-engineered medical education o Higher accreditation standards for medical schools o Higher admission standards for medical students o Fewer schools & students (especially poor, minorities, & women) o Standardized 4-year curriculum (2 didactic, 2 clinical) ❖ Abandoned the apprenticeship model ❖ Only allopathic physicians were legally recognized ✓ After WWII, medicine adopted the “biomedical model” in research & practice ❖ emphasis placed on the subcellular & molecular level of life processes. ✓ 1970s see new emphasis on social inequities ✓ 1980s & 1990s focus on response to managed care & new concerns about physician autonomy & quality of patient care ✓ Exploration of new “patient-centered care models” in 21st century 11 ❑ Pharmacy ✓ 1900: 53 colleges & depts. of pharmacy; apprenticeships no longer adequate. ✓ 1922: APA Code of Ethics primary objective “service it can render to public in safeguarding handling, sale, compounding & dispensing of medicinal substance” ✓ 1915: Flexner & Pharmacy Struggle for Professionalization ✓ 1975: Pharmaceutical care concept advanced – “pharmacist accepts responsibility for drug-use functions & provides those services governed by awareness of, commitment to, the patient’s interests.” ✓ 1990: 6-year Pharm.D. curriculum for all new students ✓ 1994 Pharmaceutical Code of Ethics ❖ Emphasizes “covenantal” relationship (ie formal agreement) with patient & service to “individual, community, & societal needs.” ✓ Medication Therapy Management in context of Medicare Modernization Act of 2003 & Medicare Part D ✓ Patient-Centered Care in Community-Based Pharmacies & Demonstration Projects that Feature Pharmacists in Medical Homes ✓ Pharmacies & Retail Health Clinics 12 ❑ From Beginning to End of the 20th Century: ❑ Leading causes of death shifted from acute diseases (i.e. influenza, pneumonia, TB) to chronic diseases (i.e. heart disease, cancer, stroke) ❑ Life expectancy increased almost 60% ❑ Three factors: 1: Improved standard of living (lifestyles) ❖ Hygiene ❖ Nutrition/Diet ❖ Housing 2: Advances in public health 3: Progress in medical practice 13 ❑ Major Hallmarks of the 20th Century 1: Increased role of all levels of government in health care. ❖ Regulation o Pure Food & Drug Act (1906) o Food, Drug & Cosmetic Act (1938) ❖ Funding o Hill-Burton Act (1946) o Medicare (1965) 2: Emergence of prepaid health services (3rd-party payments) ❖ 1929: Baylor University enrolled school teachers in “Blue Cross” to cover hospital costs. ❖ 1938: Kaiser Permanente for health care services for workers on Grand Coulee Dam ❖ 1939: “Blue Shield” for physician’s fees 14 ❑ Health Policy Overview: Public & Private ✓ Increased dependence on third-party payments for medical care due to government policies: ❖ Employers offered health insurance as a benefit to attract workers; added to negotiations by unions o Wage controls excluded benefits (i.e. health insurance) o Tax deductibility of health insurance benefit as expense for employers (but not individuals) ✓ 1965: Medicare/Medicaid instituted ✓ 1973: Health Maintenance Organization Act ❖ Required all employers with >25 employees to offer HMO option in their health plan ❖ 1995: Over half U.S. covered by HMOs or less-structured PPOs 15 ❑ Health Policy Overview: Public & Private ✓ Increased dependence on third-party payments for medical care due to 1996: Health Insurance Portability & Accountability Act (HIPAA) ❖ goals: o protect privacy o reduce healthcare fraud o keep health insurance when change/lose jobs o who can access information o penalty for non-compliance ❖ applicable to: o HC facilities; private offices; students; non-patient care employees; health plans; billing companies; EHR ✓ 1997: State Children’s Health Insurance Plan (S-CHIP): ❖ for children in marginally non-qualified Medicaid families: o include: routine check-up; immunization; MD visit; prescription; dental/vision; in-& out-patient; lab, X-ray; emergency services ✓ 2003: Medicare Prescription Drug Improvement & Modernization Act (MMA) creates Medicare Part D 16 ❑ Health Care Reform ✓ Incremental ❖ Employer mandates to provide health insurance (HMO Act) ❖ Expanded eligibility of Medicare/Medicaid (S-CHIP) o own eligibility groups, benefit packages, payment levels o funding: capped; covers fewer children; spends less than Medicaid. ❖ Managed competition (failed Clinton Plan) ❖ Health Savings Accounts (MMA) ✓ Comprehensive (i.e. universal coverage) ❖ Single-payer (government-run) ❖ Health care vouchers (choice & competition) ✓ Continued Dissatisfaction with Health Care System in U. S. in 21st Century expressed by Americans 17 ❑ Health Care Reform ✓ Patient Protection & Affordable Care Act ❖ Highest impact policy reform since Medicare & Medicaid in 1965 ❖ ACA affects virtually all Americans ❖ Obama “window of opportunity” to position reform on agenda: o problems of major scope & urgency with feasible solutions; links with other significant issues, e.g. national deficit; political will o effort to embody core principle that everybody should have some basic security when it comes to their health care.” (President Barak Obama) ❖ Incremental health reform reduces # of uninsured Americans by 32 million ❖ Provisions include: o Most individuals required to have health insurance beginning in 2014 o Health Insurers prohibited from imposing lifetime limits on coverage & prohibited from rescinding coverage, except in cases of fraud o Young adults allowed to remain on parent’s health insurance up to age 26 18 ❑ Health Care Reform ✓ ACA Intended Effects by 2019 o Cover currently uninsured ▪ except illegal immigrants ▪ low-income who do not enroll in Medicaid ▪ “opt-outs” preferring to pay the penalty o Merge public health prevention concepts into practice of “personal medical care” through an array of realigned financial incentives for providers & insurers & other population-focused initiatives 19 ❑ Collateral Effects of ACA Debate ✓ Focused stakeholders on problems of access, rising costs & questionable quality of care: ❖ can prevention & wellness become dominant focus of primary care o can wellness emphasis actually reduce costs by preserving health & avoiding costly illnesses? o can financial incentives produce better patient outcomes & a generally more “healthy” population? ❑ Problems of Health Care ✓ Decades of impressive technological advances did not resolve persistent: ❖ conflicting objectives between govt & private sector market reforms ❖ variations in patient outcomes, efficiency, & effectiveness ❖ poorly aligned infrastructure: o confusing labyrinth for patients & providers 20  ACA Provisions for Aging & Dependent Populations ❑ “Medicaid Money Follows the Person” ❑ “Community First Choice Option in Medicaid” ❑ “State Balancing Incentive Program” ✓ Fed funded state demonstration projects: ❖ Medicaid matching funds for community services & home-care assistance. Access to Healthcare ❑ Polar public & policymaker viewpoints on entitlement to basic HC: ✓ ensure access without govt interference with private practice or consumer choice ✓ Physicians as professionals obligated to provide free care versus ✓ Medical care is neither a right nor a privilege; it is a service available to those wishing to purchase it. 21  Emerging & Continuing Issues & Challenges ❑ Aging population ❑ Access to HC ❑ Quality of care ❑ Conflicts of interest Aging Population ❑ By 2040, ~ 21.7% U.S population 65+; by 2050, ~ 21% 85+ ✓ Increased longevity, immigration, culturally diverse aged ✓ Major gaps in traditional system for care of older, culturally diverse Americans ✓ Financial gaps in Medicare & Medicaid payment for older adult basic needs; state burden of nursing home care…. 22