HSC Ch 13 Notes

History of Healthcare in the US

  • Early health care in the colonial US consisted of family members and neighbors, home remedies. Anyone could be a physician

    • Considered to be more of a trade than profession

    • Hospitals only found in big cities

  • Formal health care in a physicians office shifted from home care in the late nineteeth century

    • Influence of the scientific method, increases in communicable disease

  • 1920s - Mortality rates declined due to improved public health in the early twentieth century but chronic conditions and the influenza pandemic caused them to spike

    • New medical procedures - x ray, chemotherapy

    • By 1929 - 3.9% of US GDP spent on healthcare

  • 1940s - influence of WW2 and increase in use of health insurance

    • Hospital Survey and Construction Act of 1946 (Hill-Burton Act) - provided substantial funds for hospital construction.

  • 1960s - Increased interest in health insurance

    • Third-party payment system (insurer pays/reimburses) for healthcare solidified as standard method of payment in the US

    • Led to rapid rise in costs for healthcare

    • Social Security Act + Medicare/Medicaid authorized in 1965 to assist elderly, disabled and poor to afford healthcare

  • 1970s - Health Maintenance Organization Act of 1973 - “provided both loans and grants for the planning, development, and implementation of combined insurance and healthcare delivery organizations and required that a minimum prescribed array of services be included in the HMO arrangement.”

  • 1980s - deregulation of healthcare delivery w Reagan in office

    • New medical technology - MRIs, ultrasound, more elaborate health insurance programs

  • 1990s - American Health Security Act of 1993, plan to provide universal healthcare coverage

    • Never reached the floor in Congress due to opposition

    • Managed care: system of health care delivery that (1) seeks to achieve efficiency by integrating the four functions of health care delivery, (2) employs mechanisms to control (manage) utilization of medical services, and (3) determines the price at which the services are purchased, and consequently, how much the providers get paid

      • Due to this, healthcare costs slowed

  • 2000s - President Bush + Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)

    • HSA (Health Savings Accounts), Medicare outpatient prescription drug benefits

  • 2010s - ACA (Affordable Care Act/Obamacare) signed along with Health Care and Education Reconciliation Act of 2010

    • Purposes: expand health insurance coverage, hold insurance companies accountable, lower healthcare costs, guarantee more choice, enhance quality of healthcare for all Americans

    • Set up Accountable Care Organizations specializing in Medicare patients

    • Road for implementation of these acts has not been smooth - many technical difficulties

Structure

  • Public health practice: the development and application of preventive strategies and interventions to promote and protect the health of populations

    • Importance of education, empowering communities

  • Medical Practice: services usually provided by or under the supervision of a physician or other traditional health care provider

    • Primary care: clinical preventive services, first-contact treatment services, and ongoing care for commonly encountered medical conditions

    • Secondary care: specialized attention and ongoing management for common and less frequently encountered medical conditions, including support services for people with special challenges due to chronic or long-term conditions (ex. cardiologist, gastroenterologist)

    • Teritary care: even more highly specialized and technologically sophisticated medical and surgical care for those with unusual or complex conditions (generally no more than a few percent of the need in any service category) (ex. specialty surgeons, cancer physicians)

  • Long term practice

    • Restorative care: provided to patients after surgery or other successful treatment, during remission in cases of an oncogenic (cancerous) disease, or when the progression of an incurable disease has been arrested

    • Long term care: help that people with chronic illnesses, disabilities, or other conditions that limit them physically or mentally need

      • should (1) fit the needs of different individuals, (2) address their changing needs over time, and (3) suit their personal preferences

  • End-of-life practice: healthcare services provided to individuals shortly before death

    • Hospice care: a cluster of special services for the dying, which blends medical, spiritual, legal, financial, and family support services

  • Independent Provider: healthcare worker who has the specialized education and legal authority to treat any health problem or disease that an individual has

    • Allopathic provider: provider who uses a system of medical practice in which specific remedies for illnesses, often in the form of drugs or medication, are used to produce effects different from those of diseases

      • Usually have the title MD

    • Osteopathic provider: doctor of osteopathic medicine (DO) or the recognition of the reciprocal interrelationship between the structure and function of the body

    • Nonallopathic provider: provides nontraditional methods of healthcare (acupuncture, herbalism, etc) (ex. chiropractors) called complementary/alternative medicine (CAM)

  • Limited/restricted care providers

    • Nurses - registered nurse (RN), licensed practical nurse (LPN)

    • Physician Assistants

    • Allied health professionals - complement other healthcare professionals

    • Public health professionals

  • Healthcare facilities

    • Inpatient: hospitals, nursing homes, assisted-living facilities

      • Private and public hospitals, voluntary hospitals

    • Outpatient: Ambulatory care, such as surgical centers

      • Clinics found in pharmacies, urgent cares

Function

  • Healthcare is complicated because its policies are intertwined with other policies like the US tax code

  • Cost containment, access, and quality triangle (Kissick)

    • If one angle is expanded the other two are compromised

    • To improve healthcare the right combination of policy and accountability must be reached

  • Health insurance coverage and the generosity of coverage are major determinants of access to health care

    • Since the ACA has been signed, the % of uninsured patients has declined, but many people still do not have proper access to health insurance, especially minority groups

    • Those without health care are less likely to seek out preventative care (seeing a primary care physician) than urgent or emergency care

  • The Health Insurance Marketplace (or exchange) is an organization that was set up to create more organized and competitive markets for buying health insurance

    • Can be run by state or federal gov

    • Consumers can compare plans based on price, benefits, quality, and other features important to them before making a choice

  • Characteristics of quality healthcare

    • Effective - based on scientific evidence

    • Safe - avoids injuries to those being treated

    • Timely - reduces waits and harmful delays

    • Patient-centered - responds to individual needs, values

    • Equitable - does not vary in quality/discriminate

    • Efficient - Max. resources, avoids waste

  • National Committee for Quality Assurance (NCQA)

    • Nonprofit

    • Assesses and accredits healthcare plans

  • The Joint Commission

    • Predominant accrediting organization

  • Cost of healthcare

    • In 2018, health expenditures grew 4.6% to $3.0 trillion and consumed 17.7% of the gross domestic product (GDP).

    • $11,172 per person in 2018

    • Under the US system, cost is usually not known until after the service has been provided

    • Why are costs rising?

      • Coverage expansions under the ACA

      • Paying providers and hospitals in ways that reward doing more, rather than being efficient

      • Increase in aging pop. with chronic conditions

      • Demand for medical advances

      • Supply chain issues

    • Resource-based relative value scale (RBRVS)

      • Created for Medicare to reimburse physicians according to the relative value of the service provided

    • Prospective reimbursement, referred to as the prospective pricing system (PPS), “uses certain pre-established criteria to determine in advance, the amount of reimbursement”

    • Pay-for-performance (P4P) or “value-based purchasing” is a payment system that offers financial rewards to providers and facilities for meeting, improving, or exceeding quality measures (i.e., process, outcome, patience experience, and structure) or other performance goals

      • Created to improve the efficiency of healthcare

      • May include penalties

  • Health Insurance

    • Health insurance policy: contract between an insurer (i.e., private insurance company or the government) and an individual (known as the insured or policyholder) that outlines in exact terms what healthcare services are covered, how the insured will be compensated, the cost of the policy to the insured (i.e., premium), and any associated information, for example, the mode of premium payment or deductibles

      • Deductible: amount of money that the beneficiary (insured) must incur (pay out of pocket), generally up to an annual limit before the insurance company begins to pay for covered services

      • Copayment: negotiated, set amount a patient pays for certain services

      • Fixed indemnity, refers to the maximum amount an insurer will pay for a certain service

    • Self-funded insurance program: pays the healthcare costs of its employees with the premiums collected from the employees and the contributions made by the employer instead of using a commercial carrier

    • Medicare: federal health insurance program for people 65 years of age or older, people of any age with permanent kidney failure, and certain disabled people under 65

      • Part A: Covers inpatient services such as hospital stays

      • Part B: Covers outpatient services such as routine doctor’s visits

      • Part C: Medicare advantage, an alternative plan to Medicare A and B that includes dental, vision insurance

      • Part D: Covers the cost of prescription drugs

    • Medicaid: a health insurance program for low-income Americans

    • Children’s Health Insurance Program (CHIP): created as part of the Balanced Budget Act of 1997 and funded for 10 years. It was enacted to provide coverage to eligible low-income, uninsured children who do not qualify for Medicaid

      • State-federal funded

    • Issues with Medicare, Medicaid

      • Lengthy paperwork

      • Some practices do not accept

      • Medicare/Medicaid fraud

    • Medigap: (Medicare Supplement Insurance) policies that cover the “gaps” not covered by Medicare

  • Managed Care: a system that integrates the functions of financing, insurance, delivery, and payment and uses mechanisms to control costs and utilization of services

    • Offered by managed care organizations (MCOs)

    • Preferred provider organizations and health maintenance organizations