HMP 600 - Quiz 1

How we define health varies based on…

values, existinand g social conditions, cultural norms, personal factors

Health is a product of many…

interrelated and overlapping factors that change over time, and has so much to do with the world around us and individual behavior

What is the last line of defense to protect and ensure health (like goalie in soccer)?

Medicine and healthcare services

What doesn’t necessarily meet our needs or expectations when treating individual or population health?

Healthcare services and the healthcare system

The 2 models of healthcare delivery

Regionalized and dispersed

Regionalized Delivery System

• The organization and coordination of all health resources and services within a defined area

• Different types of physicians and facilities are assigned to distinct tiers in the primary, secondary, and tertiary levels in an ordery/regulated fashion

  • Planned distribution of care types/locations based on population

• Focus on primary care

• Care coordination between levels of care (more specialized care requires referral from lower levels)

Primary Care

Prevention and Wellness: Focuses on routine checkups, immunizations, screenings, and lifestyle counseling to stop health problems before they start.

Secondary Care

Medical care provided by medical specialists and community or regional hospitals when a patient needs advanced expertise beyond the scope of a general primary care doctor

Tertiary Care

Highly specialized, advanced medical treatment provided in major hospitals or specialized medical centers

• Patients usually need a referral from a primary or secondary care provider to get in.

• It treats severe, rare, or life-threatening health issues

Pros of Regionalized Models

• Universal access to primary care

• Efficient use of resources (simplified admin system)

Cons of Regionalized Models

• Requires coordinated investment & management

• Delays in delivering specialty care (ie. specialist shortages)

Dispersed Model

• Independent providers of care decide location/service

• Patient choice of providers

• Focus on specialized care

• Many different providers at each level

• Incomplete coordination between/across levels

Pros of Dispersed Model

• Patient Choice

• Provider Incentives

Cons of Disbursed Model

• Excess resources in some places, limited resources in others (rural health providers)

• Care might be fragmented and uncoordinated

Which model of healthcare delivery does the US have?

Dispersed model

Why does the US have a dispersed model of healthcare delivery?

- services (physicians, hospitals, etc). are private, evolution of financing health insurance in US
- regulation did not control growth or plan for coordination of hospitals or health services

Hill Burton Act (Hospital Survey & Construction Act)

• After WW2, funding of non-coordinated growth of private hospitals

• Federal matching funds to states for hospital construction (new and expansion), to ensure adequate supply of hospital beds

• An obligation to provide emergency services to any person living in its service area who cannot afford those services (“community benefit” obligation of hospitals)

Certificate of Need Laws

• Used as a check for hospital growth

• New York State created the first law to limit/regulate hospital growth in 1964

• 1974: National Health Planning & Resources Development Act

  • Required states to adopt Certificate of Need (CON) Laws to get hospital building approval by showing need to the state to build hospitals (so that there can be areas that aren’t underbuilt or overbuilt)

  • To regulate expanding bed capacity, establish new or expanding health services, technological expenditures,

Hill-Burton Long-Term Impacts

• Made the hospital the center focus of health care delivery

• Government involved in direct support of health care, but not in planning distribution (compare to regionalized delivery model)

• Left a legacy of small (inefficient) hospitals

• Led to unplanned, uncoordinated growth

Non-Profit Hospital

• Exemption from federal income tax

• Must provide "community benefits" (averages 8% of operating expenses), works to contribute to the community for the greater good

• Exempt from state and local property taxes

• Use of tax-exempt bond financing

• Can accept charitable contributions (also may be tax-deductible for donors)

For-Profit Hospital

• Provide health services to generate revenue/profits (legal obligation to promote wealth of shareholders within boundaries of law)

• Surplus revenues go to owners/shareholders

What are community benefits?

Obligations for non-profit hospitals, Affordable Care Act (ACA) - added 4

Vertical Integration

The integration in one company of two or more stages of production (levels of supply chain) normally operated by separate companies

• Supply chain is under 1 company

Horizontal Integration

The expansion of one company through internal expansion, acquisition or merger of two or more companies at same level of production in industry (supply chain)

• Expansion to a company by adding more chains under it (mergers and acquisitions within the supply chain)

Community Health Needs Assessment (CHNA)

Evaluation of community health requirements and resources (financial barriers to care, adequate nutrition, SDOH)

• One of the community benefits that the ACA added for non-profit hospitals (needs to happen every 3 years)

Private Equity

A form of for-profit health care company ownership reflecting investment in healthcare facilities by private parties.

• Shares of private, investor-owned organizations such as private equity own firms aren’t traded on public markets (they aren’t required to follow the same regulations as public companies)

Impacts of PE on Healthcare

• Increase healthcare prices

• Not better healthcare quality despite being more expensive

• Private equity acquisition increase physician turnovers (ohysicans leaving the practice)

• Increased reliance on nurse practitioners and PAs

Definition of Safety Net Providers (in Primary Care)

• Not for-profit and public organizations who have a legal obligation or commitment to provide comprehensive primary care to underserved communities in rural & urban areas

  • Serve primarily low-income patients, and populations of color (important services for millions of patients)

  • Rely heavily on allied health professionals (NPs, PAs, RNs, etc.) , funding model and "payer mix" primarily - public sources

Safety Net Providers (4)

1. Not for-profit and public organizations (ie. private & public hospitals)
2. Federally Qualified Health Centers (FQHCs) - Qualified grant funding under the Section 330 of the Public Health Service Act, federal oversight
3. Look-alike health centers (Meet PHS 330 Eligibility but don’t receive funding)
4. State & local community health centers

Federally Qualified Health Centers (FQHCs)

• Qualified grant funding under the Section 330 of the Public Health Service Act, federal oversight

Look-alike Health Centers

• Looks like and functions like a FQHC, but doesn’t receive federal PHS 330 funding while eligible

  • Sometimes doesn’t want federal oversight

  • Might not have the money/resources to apply for funding

Indian Health Service (IHS)

• Mission is to raise the physical, mental, social, and spiritual health of American Indians and Alaska natives to the highest level

• The only department of HHS whose principal mission is to deliver health services directly to individual citizens

History of Indian Health Service (IHS)

• The US government promised native people health services in exchange for treaty terms (land) in the constitution in 1787

• Native people face many health disparities and negative health outcomes from centuries of negative treatment (smallpox, tuberculous, etc)

Challenges of Safety Net Providers

• Resources

• Staffing

• Funding Models

• Patient Populations

Healthcare Provider Deficiency

Gap between the adult populations demand for primary care services and the capacity for primary care, as currently delivered, to meet demand

Healthcare Provider Shortage

Suggests that simply producing more physicians will address the primary needs by eventually meeting demand

Why do we have a shortage of primary care physicians?

• Access problems (can’t find appointments, long wait times)

• More demand (changes in population, aging more sick population)

• Shortage of providers

• Changes in future supply of providers (retiring, nurses leaving due to burnout)

The 5 A’s

1. Affordability
2. Availability
3. Accessibility
4. Accommodation
5. Acceptability

Affordability

Cost of care to patient (including of getting to services)

Availability

• Presence of providers

• Wait times for appointments

• Flexible appointment times

Accessibility

• Distance to provider location

• Type of transportation

• Mode of access/appointment

Acceptability

Extent of patient comfort with provider (language/communication barriers, trust, cultural competency)

Health Professional Shortage Areas (HPSAs)

Geographic areas, population groups, or health care facilities that have shortages of dental, mental health, or primary medical care providers

Medically Underserved Areas (MUAs)

Geographic areas and populations with a lack of access to primary care services

1972 National Health Services Corps (NHSC)

Supports more than 18,000 primary care medical, dental, and behavioral health providers through scholarships and loan repayment programs to serve in HPSAs (typically in CHCs/FQHCs)

Shortage of (diverse) clinical providers

the lack of minority health professionals is compounding the nations persistent racial and ethnic health disparities

How can we address the deficiencies in primary care?

• Recruit and train more physicians in primary care, particularly from under-represented racial/ethnic minority groups

• Support physicians working in underserved areas

• Expand use of non-physician clinicians: allied health professionals (working to full scope of practice abilities)

  • Remember that licensure of different types varies by state

• Expand use of non-clinical personnel and role of new technology

What other populations need long-term care (LTC) or long-term support or services LTSS other than the elderly 65+ years old?

Those who need support with activities of daily living (eating, walking, dressing, bathing, etc.)

• Disabled people

• Recovery from surgery/injury

Home and Community-Based Services (HCBS)

Community-based population living at home needs for long-term care

• Roughly 11M people

• Half aren’t elderly

• 13% are getting paid caregiving support

Institutional Sources of LTC & LTSS

• Nursing Homes

• Skilled Nursing Facilities

Are most providers of LTSS (regardless of type) for-profit or non-profit?

For-profit

What has significant deficiencies in institutional LTC & LTSS?

Quality of long-term support or services

Challenges of the LTC & LTSS Industry

• Understaffing (COVID-19 exacerbated staffing needs)

  • Some state-level policies can address deficiencies in workforce

Skilled Nursing Facility

For rehabilitation/therapy and recovery beyond the scope of regular hospital acute care (where you can immediately go home after treatment)

• Provides on-going medical care/treatment

• Usually for-profit, or paid partially by Medicare (actual medicare treatment)

Residential Long-Term Care

When a person has a long-term chronic illness or disability, a gradual onset, or a chronic-progressive/disability

• Not medical care/medical treatment

• Social service model (residental needs), while going to the doctor or nurse independently