History of Healthcare Systems

Pre-1850

• constant epidemics and very little medical knowledge

• societal view on sickness: if sick, you deserved it (poor morals or sin)

Phase I: Institutionalization of Healthcare

• industrial revolution spread globally

• Great Sanitary Awakening: understanding concept of hygiene

  • people getting sick because of impure food/water, poor sewage, and crowded housing

• Industrialization cause more people to move to urban locations → increased spread of disease

• thinking became more about prevention than treating disease as came up

• advancements in scientific and medical knowledge

Phase II: Scientific Method in Medicine

• pre-federalization

• infections spread person to person

• Advancing techniques and medical info

  • Flexner Report

• Educating public about health to prevent illness

• Great Depression → change in societal attitudes

  • emphasis on social responsibility

• FDR’s New Deal funding federal work programs, putting in place Social Security Act and establishing minimum wage

Flexnor Report

Foundation of medical education during Phase II

Phase III: Social and Organizational Structure of Healthcare

• Main concern: chronic diseases

• fastest/greatest growth of medical sciences and technology advancements (discovered penicillin)

• gov’t responsible for healthcare and funded everything but cost became too high

Hill-Burton Act

Phase III.

Funded the construction of hospitals/clinics

Health Amendments Act

Phase III.

Increased number of physicians by providing funding for schooling through grants

Kerr-Mills Act

Phase III.

Solidified healthcare as right and not privilege

Johnson’s Great Society

Phase III.

Title 18: established Medicare for elderly

Title 19: established Medicaid for the poor.

SS Amendments

Phase III.

Tied to title 18/19 and established Social Security. People 65+ years automatically enrolled in Medicare and would receive benefits as part of financial contributions into SS. Helped people with disabilities who could not work regularly or support themselves.

HMO Act

Phase III>

Established the HMO plan – offered as 4 tiers.

Prepay physicians so could see them at no cost, but have to stay within network.

Health Systems Agencies (HSAs) Established

Phase III

Would analyze spending costs within healthcare system

Phase IV: Defederalization and Competitive Healthcare Market Era

• Main health concern: chronic disease, emotional/behavioral health

• development of managed care, physician group practice, and home health care

  • gov’t didn’t regulate healthcare system so insurances stepped in

• System more organized and centralized

  • greater focus on reducing costs

• technology continues to grow

Omnibus Reconciliation Act (OBRA)

Phase IV.

Cut funding for hospitals and grants for providers pursuing med school

Creation of Peer Review Organizations

Phase IV.

Analyzed spending costs and worked to figure out how to minimize them. Replaced PSROs.

Prospective Payment System for Hospitals

Phase IV.

System calculated a budget for each diagnosis based on location and type of hospital. Hospital then has to follow budget to treat patient, and any costs beyond had to be paid out of pocket by hospital.

Medicare Prescription Drug, Improvement, and Modernization Act

Phase IV.

Created Medicare Part D.

Patient Protection and Affordable Care Act

Phase IV.

Aka Obamacare, requiring that everyone has health insurance.

Current Trends: Predominant Health Problems

Chronic diseases, emotional and behavioral issues

(evolved from treating acute infections when not known how people became sick)

Current Trends: Social Context of Health

• responsibility: individual responsibility that changed to social responsibility

  • healthcare transitioned to institutional, ambulatory and community based

• Societal thoughts:

  • then: sinful and deserved it

  • now: causes of illness

Current Trends: Technology

• developed healthcare system filled with centralized network of providers

Current Trends: Cost of Healthcare

• generally federally dominated; government is largest purchaser of healthcare bc medicare/medicaid/federal programs

• healthcare changed from capacity to market based

• costs very expensive now ever since phase III’s spending when expanding healthcare

Issues in Current System: Out of Control Spending

Led to Prospective Payment System to minimize costs of treatment to what is “most necessary”

Issues in Current System: High Rates of Uninsured Patients

• caused by creation of different subsystems that let patients fall through cracks

• make just enough to not qualify for Medicaid but not enough for private insurance or employer does not provide

• creation of PPACA to address high insurance rates

• ACA brought greater gov’t oversight to address disparities

PPACA

• created to address high uninsurance rates

• mandates everyone has health insurance and meant to improve quality and efficiency of healthcare

• Title 1: ensuring access to to healthcare

• Title 2: analyze how we can use public health better

• Title 8: CLASS Act – helped with assistance services

• Title 9: Revenue Provisions

• Title 10: Native Americans’ health insurance protected and provided on reservations

Affordable Care Act (ACA)

• provided payment reform to reduce payments for treatments/hospitalizations that resulted from poor quality of care

• funded comparative research that analyzed the different interventions and strategies to prevent/diagnose/treat/monitor health conditions

Middle Class Model

• regularly employed, middle income with continuous health insurance coverage

• continuity of care: services coordinated by family PCP

• financing: paid by patient or private funds

• decision making: allowed considerable amount of decision, control, and choice of providers/plan

• services: amb care provided by physicians

  • hospitals within community

  • long term care ‘ skilled nursing facillities

• gov’t assistance: medicare after 65+ years

Poor Model

• poor/employed or underemployed patients without continuous health coverage

• continuity of care: no single provider or continuity of care

• financing: services usually free/low cost by hospitals/local public health departments or gov’t assistance

• decision making: no control over provider or service quality

• services: amb care by public health, ER, pharmacists

  • hospitals: usually local, city, or county nonprofits

  • long term care → extension of hospital stay

• gov’t assistance: medicaid if eligible and later medicare

  • limited by cost sharing

Tricare

• for active duty military personnel and dependents

• pros

  • well organized

  • centrally planned

  • integrated, comprehensive, omnipresent

  • all enlisted automatically eligible

  • no cost to patient and high quality care

  • emphasis on wellness/prevention/early detection

• cons

  • no choice of provider or treatment

VA

• for retired, disabled veterans of previous military service

• largest single healthcare provider in US

• part of VA system

• pts predominantly male

• high incidence of chronic, physical and mental illness

• providers salaried personnel

• pros

  • hospitals self sufficient and self contained

• cons

  • eligibility is unclear

PPO

higher premiums, but patient gets to choose who they want to see

• patient usually has to pay copay or coinsurance

• created first but became too expensive

HMO

uses prepay system and get assigned PCP within network

• mostly see PCP for issues unless require specialist which will likely need referral from PCP

• 4 tiers: bronze, silver, gold, platinum