Healthcare Delivery and Aging Population Notes
Healthcare Delivery in US (Chapters 26 & 27)
- Unlike other developed countries, healthcare delivery in the US is delivered by many providers in many settings.
History of Healthcare Delivery in US
Pre-1800s
- Self-care was common from colonial times (late 1800s), where anyone (un)trained could practice medicine.
- Medical education was not as rigorous as today; early medical education was experience-based.
- Location of care:
- Hospitals: Institutions built, staffed, and equipped for disease diagnosis and treatment.
- Almshouses (poor houses): For homeless, aged people without means, the mentally ill, epileptics, blind/deaf, etc.
- Pesthouses (plague, pest, fever shed): Institutions where those suffering from infectious diseases were confined and treated.
Late 1800s to Early 1900s
- Care moved from patient’s home to physician’s office/hospital.
- American Medical Association (AMA) established in 1847.
- Professional membership organization for physicians, driving force for the concept of private practice in medicine.
- Responsible for standardizing medical education.
- Science and mortality decline.
- Early 1920s: Chronic diseases surpassed communicable diseases as leading causes of death (COD).
- New procedures/instruments: electroencephalograph, electrocardiogram, Pap smears, disc penicillin, iron lung.
- Training specialized.
- 1929: 3.9% GDP on healthcare.
- Two-party system – patients and physicians.
1940s and 1950s
- WWII impact: Employer-provided health insurance.
- Hill-Burton Act
- Hospital Survey and Construction Act of 1946.
- Gave hospitals, nursing homes, etc., grants/loans for construction/modernization.
- Improved procedures, equipment, facilities (increased cost of care).
- Health care (basic right vs. privilege).
1960s
- Shortage of quality care and maldistribution of healthcare services.
- Increased interest in health insurance.
- 3rd party payment system.
- Cost of health care rose.
- July 30, 1965: President Lyndon B. Johnson signed into law legislation that established Medicare/Medicaid.
1970s
- Health Maintenance Organization Act of 1973 (HMO Act)
- Federal law provides trial federal program to promote/encourage development of HMOs.
- National Health Planning and Resources Development Act of 1974
- Health system agencies: cut costs/prevent unnecessary spending.
1980s
- Dereg of healthcare delivery (role of competition).
- New medical technology and elaborate health insurance programs.
1990s
- American Health Security Act of 1993.
- Managed care: achieve efficiency, control utilization, determine prices and payment.
- Percentage GDP and $ spent on HC increases.
- CHIP (Children’s Health Insurance Program)
- Coverage to uninsured children not eligible for Medicaid but can’t afford private coverage.
21st Century
- Medicare Prescription Drug Improvement, and Modernization Act of 2003.
- World Health Report 2000 – Health Systems: Improving Performance
- US ranked 37/191 countries.
- CHIP Reauthorization Act of 2009.
- Patient Protection and Affordable Care Act of 2010 (ACA, PPACA, or ‘Obamacare’
Spectrum of Health Care Delivery
- Health Care System Structure:
- Spectrum of HC delivery (different types of care).
- Types of HC providers.
- HC facilities in which HC is delivered.
- Spectrum:
- Public Health Practice
- Disease prevention and health promotion, specific protection, and case findings
- Health Edu: empowerment and motivation
- Governmental health agencies
- Medical Practice
- Primary medical care
- Clinical protective services; 1st contact treatment; Ongoing care for common conditions
- Secondary medical care
- Specialized attention and ongoing management
- Tertiary medical care
- Highly specialized and technologically sophisticated med/surg care for unusual/complex conditions
- Long-term Practice
- Restorative Care – provided after surgery/treatment
- Rehab, therapy, home-care, in/out patient units, nursing homes, etc
- Long-term care to help with chronic illnesses and disabilities
- Time-intensive skilled care to basic daily tasks
- End of Life Practice
- Services provided shortly before death
- Hospice care: terminal diagnosis (life expect <6 months)
Types of Health Care Providers
- 17 million HC workers in US (14% of jobs)
- Over 200 types of careers in industry
- Independent providers
- Limited care providers
- Nurses
- 4 million+ in US
- Training/edu:
- Licensed Practical Nurses (LPN)
- Registered Nurses (RNs)
- Professional Nurses (BSN)
- Advanced Practice Registered Nurses (APRNs – MSN, DNP)
- Nonphysician practitioners
- Allied health care professionals
- Public health professionals
- Work in PH orgs, HC orgs, govt orgs, school systems
- Financed by tax $ or grants
- Available to anyone; primary service $ disadvantaged
- PH physicians, environ hlth workers, epidemiologists, hlth edu, PH nurses, research sci, clinic work, biostatisticians
- 4316.9 other jobs in health care sector
- 12229.0 health care occupation jobs in HC settings
- 5256.3 health care occupations jobs in other sectors
- 39% in hospitals; 26% outpatient; 20% nursing/residential; 8% each home health, lab, ambulatory
Health Care Facilities
- Physical settings HC provided; o
- Inpatient care
- Hospitals, nursing homes, assisted-living
- Outpatient care
- HC practitioner office, clinic, primary care center, ambulatory surgery centers, urgent care, services in retail stores, dialysis centers, imaging centers
- Rehab
- Long-term care
- Nursing homes, group homes, transitional care, day care, home health care
Accreditation of Health Care Facilities
- Assists in determining quality of HC facilities
- Evaluation of predetermined standards
- Accreditation Agencies
- Joint Commission (JCAHO)
- National Committee for Quality Assurance (NCQA)
- American Medical Accreditation Program (AMAP) American Accreditation HC Commission/Utilization Review Accreditation Commission (AAHC/URAC)
- Accreditation Association for Ambulatory HealthCare (AAAHC)
HC System Function
- US ‘system’ unique to other countries
- Affordable Care Act 2010
- Extends coverage
- Curbs health insurance abuses
- Initiates improvement in quality of care
- US Structure – complex, expensive, many stakeholders, intertwined policies, politics
- Major issues
- Cost containment, access quality
- All ==== important; expansion of 1 comprises other 2
Access to Health Care
- Insurance coverage and generosity of coverage are major determinants of HC access
- Uninsured
- 2018: 27.5 million (8.5%)
- 2015: 28.8 million (9.1%)
- 6 million fewer than 2013 and 17.5 million fewer than 2011
- Likelihood of being insured greater for: Young, more educated, low income, nonwhite, male.
- Greatest reason for lack of insurance: cost, lost job, change in employment.
- Lack of primary care access
- Factors limit access are lack of health insurance, inadequate insurance, and poverty
- Major component of ACA
- Increasing # americans with health insurance
- Health Insurance marketplaces
- Organizations established to create more organized and competitive markets for purchasing health insurance
Quality of Health Care
- Quality should be: effective, safe, timely, patient centered, equitable, efficient
- Groups measure quality:
- Agency for Healthcare Research and Quality (AHRQ)
- National Quality Strategy (NQS)
- Mandated by ACA
- Guide by 3 aims: better care, healthy people/communities, affordable care
- National Committee for Quality Assurance (NCQA)
Cost of and Payment for Health Care
- In 2018, health expenditures:
- Up from 2014, health expenditures: 3.1 trillion
- US biggest spender on HC in world by total spent
- Payments come from 4 sources:
- Direct or out of pocket payments
- 3rd party payments from private insurance, govt insurance programs, other 3rd party payers
- Reimbursement
- Fee for service
- Packaged pricing
- Resource based relative value scale
- Capitation
- Prospective reimbursement
Health Insurance
- Risk of cost spreading process like other insurance
- Cost is shared by all in group
- Generally equitable but increased risk may lead to increased costs
- Policy, premiums, deductible, co-insurance, copayment, fixed indemnity, exclusion, pre-existing condition
- Cost of insurance mirrors costs of care
- US burden falls on employer then the employee
- Increased worker share of premium
- Raising deductibles
- Increasing Rx co-pay
- Increasing # exclusion
- Cost of policy determined by risk of group and amount coverage provided
- Self-funded
- Program created for/by employers rather than commercial insurance carriers
- Generally for larger companies, unless low risk employees
- Provided by government (only available to select groups)
- Medicare
- Covers 60 million people
- Federal health insurance for 65+, permanent kidney failure, certain disabilities
- SSA handles enrollment
- Contributory program through FICA tax
- 4 parts:
- Hospital insurance (Part A)
- Medical insurance (Part B)
- Managed Care Plans (Part C)
- Rx drug plans (Part D)
- Medicaid
- For low income, no age requirement
- 72+ million covered
- Eligibility determined by each state; very costly for states
- Noncontributory program
- Children’s Health Insurance Program
- Created 1997 for 10 years
- Reauthorized in 2009 - 2013 and funding assisted by increase in federal excise tax rate for tobacco
- Targets low income children ineligible for Medicaid
- State/federal programs
- Problems with Medicare and Medicaid
- Created to provide health care to those who might have impossibilities of obtaining health insurance
- Recurrent problems
- Providers not accepting Medicare/Medicaid as forms of payment
- Medicare/Medicaid fraud
- Supplemental Health Insurance
- Help cover out of pocket costs not covered thru primary insurance
- Medigap
- Other supplemental
- Long term care insurance
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- Common features: provider panels, limited choice, gatekeeping, risk sharing, quality management, use review
- Types:
- Preferred Provider Org (PPO)
- Exclusive Provider Org (EPO)
- Health Maintenance Org (HMO)
- Closed panel
- Open panel
- Mixed model
- Staff Model
- Independent Practice Assoc (IPAs)
- Point of service (POS) option
- Medicare advantage
- Medicaid and managed care
Other Arrangements for Delivering Health Care
- National health insurance
- System where federal government responsible for HC costs of entire population paid for with tax
- 7 failed attempts in US over past 70+ years
- Consumer-directed health plans (CDHPs)
- Health savings account
- Flexible spending accounts
- Medical savings accounts
- Affordable Care Act
- 3 primary goals
- Make affordable health insurance available to more people
- Expand Medicaid program to cover all adults with income below 138% federal poverty level
- Support innovative medical care delivery methods designed to lower costs of HC generally
- Provisions
- Children stay on parent’s insurance plan until age 26
- Many preventative services free to insured patients
- Medicare Rx drug coverage more affordable
- States can opt to receive federal funds for expansion of Medicaid to uninsured
- Regulations
- Individual mandate to have health insurance or pay fine (abolished in 2017)
- Large business pay assessment if don’t insure employees
- Insurance companies can’t
- Have lifetime limits on health coverage
- Cancel policies of patient when medical costs rise
- Spend too much on admin costs or profits
Public Health and Aging Population (Chapter 29)
- The number of older adults and proportion in total population increased significantly in the 20th and early 21st centuries.
- Represent 15% of population (1 in 7 Americans)
- Young old (65-74)
- Middle old (75-84)
- Old old (85+)
Aging Myths
- Lose memory as age
- Genetic health conditions can’t be avoided as people age
- Elderly people less adaptable to change
- Elderly people less adventurous
- People become less productive as age
- Old people have “old ways” of thinking
- Old people are crabby or depressed
- Old people are incompetent
Aging Truths
- Agism: prejudice and discrimination against older adults
- Common myths not accurate representation of older adult
- Reality
- Majority older adults are active/well
- Many still work
- Many strongly engaged in community, volunteer and advocacy programs
Demography of Aging
- Size and growth of older adult population
- Number and proportion of older adults grew significantly
- 33% increase last 10 years
- Older adult population projected to continue growing; baby boom gen
- 85+ fastest growing segment of older population
- 129% increased by 2040
- 2016 – more than 80,000 persons age 100 and over
- Growth in median age
- 1970 – 28.1
- 1990 – 32.9
- 2019 – 38.2
Factors Affecting Population Size and Age
- Fertility rates
- Baby boomers: 1946 – 1964
- Mortality rates
- Life expectancy has continued to increase
- Significant increase in 20th century
- 1900 – 48 years
- 1950 – 66 years
- 2000 – 75 years
- 2019 – 78 years
Dependency and Labor Force Ratios
- Dependency ratio: economically unproductive to economically productive
- Traditionally defined by age
- Can be used for social policy decision making
- Labor force ratio: # people actually working and those who are not, independent of ages
- Ratio of workers to dependents will be lower in future than today
Other Demographic Variables
- Affect community health programs for older Americans
- Marital status
- ¾ older men married; over ½ older women married
- Older women 3 times more likely widows
- # divorced older adults continue to rise
- Concerns: lack of retirement benefits, insurance, lower net worth assets
- Living arrangements
- Closely linked to income, health status, availability of caregivers
- ½ non-institutionalized older adults live with someone (women more likely alone)
- 3.4% older adults live in nursing homes
- ¾ nursing home residents are women
- ½ resident are 85+
- Racial/ethnic composition
- US older population growing more diverse
- 2016 older adults
- 77% white, 9% black, 8% Hispanic, 4% Asian, 0.5% AIAN, 0.1% HPI, 0.9% 2+
- % white older will decline and older Hispanic will become largest minority group in US
- Geographic distribution
- More than 60% live in 13 states
- CA, FL, TX, NY, PA, OH, IL, MI, NC, NJ, GA, VA, AZ
- CA is greatest number and FL is greatest proportion
- Some states “age” bc inward migration (FL) young people leave (farm belt)
- 81% older 65+ live in metropolitan areas
- Economic status
- 1970 – 25% older adults lived in poverty
- 2016 – 9.3% lived in poverty
- Major sources income:
- Social security (reported by 86%)
- Income from assets (reported by 51%)
- Private pensions (reported by 27%)
- Govt employee pensions (reported by 14%)
- Earnings (reported by 28%)
- Education
- % older adults who completed HS rose by 28% in 1960 to 84% in 2017
- 25% older had bachelor’s degree+ in 2017 (different by race/ethnicity)
- Baby boomers most educated cohort in US history
- Housing
- Most live in adequate, affordable housing
- 81% own and 19% rent
- Older adults homes tend to be older, of lower value, and in need of repairs than homes of younger
- For most older, housing represents an asset
Health Profile of Older Adults
- Health Status of older adults has improved over years (living longer, functional health)
- Chronically disabled has been decreasing
- Health status usually not as good as younger
Morbidity
- Top causes of death for older (responsible for almost 2/3 of adults)
- Heart disease
- Cancer
- CLRD
- Stroke
- Alzheimer’s disease
- Activity limitations increase with age
- Chronic conditions
- Substantial burden on health and economic status of individuals, families, and nation
- Impairments
- Very prevalent in older adults and may be sensory, physical or memory
Health Behaviors and Lifestyle Choices
- Generally have more favorable health behaviors than younger counterparts
- Less likely to consume large amounts of alcohol, smoke cigarettes, or be overweight
- Areas for improvement: physical activity, immunizations
Physical Activity
- Older adults least physically active of any age group
- Loss physical fitness due to aging, chronic conditions
- Physical activity recs for older adults same as other adults
- Only 11% older adults meet physical activity guidelines
Nutrition
- Dietary concerns for older adults include:
- reduced sodium intake
- reduced caloric needs
- increased vegetable consumption
- increased water consumption
Obesity
- Number obese older adults increased
- 2010 38% of those 65+ were
- Only 26% older adults are in healthy weight range
Cigarette Smoking
- Over 9% of older are cigarette smokers
- number decreased significantly past few decades
- special concern: older former smokers
Vaccinations
- Immune systems weaken with age
- Rec immunizations for older
- 2014-2015 flu season, 66.7% older received flu vaccine
- 60% received pneumococcal vaccine
- Vaccine rates among older adults improved over time (racial disparities exist)
Mistreatment of Older Adults
- Reports increased greatly recently
- all states set up reporting systems
- Special problems for older
- dementia and cognitive impairment
- past experience with domestic violence
- frailty and social isolation
Instrumental Needs of Older
- 6 instrumental needs determine lifestyle for people of all ages; aging alters needs
- Income
- changes in types of expenses in elder years
- achieving older status reduces income needs
- improved significantly recently
- social security major source income
- unmarried women and minorities highest rates poverty
- Housing
- major needs: appropriateness, accessibility, adequacy, affordability
- changing residence has negative effects
- variety housing options available
- independent living, assist living, continuing care retirement communities, nursing homes, afford housing
- Personal care
- 4 levels of tasks need assist: instrumental, expressive, and cognitive tasks, tasks of daily living
- activities of daily living (ADLs): measure functional limitations
- instrumental activities of daily living (IADLs): measure more complex tasks
- Health care
- older adults heaviest users of HC services
- use HC services increase with age
- most spent on HC last years of life
- medicare primary source of payment (major changes in future)
- Transportation
- allows to remain independent
- greatest influence on transportation needs: $ and health status
- many challenges for public transportation
- solutions for transportation of older adults
- Community facilities and services
- Older Americans Act of 1965 (OAA) increase services and protect rights of older adults
- National nutrition programs
- State Departments on Aging and Area Agencies on Aging
- Other programs
- Services vary greatly across country
- Meal service
- homemaker service
- chore and home maintenance
- visitor service
- adult day care
- respite care
- home health care
- senior centers
- other services
Caregivers
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- Research beginning to give clues on risk factors
- (non)genetic factors play role
- physical exercise found to be protective
- no cure exists, but some meds delay progression
- experimental vaccine halted due to side effects
- Medications
- elderly take drugs for many conditions