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
    - Preserve assets, prevent need for family/friend to provide care, enable longer independence, easier to go to facility by choice

Managed Care

Goal to control costs by controlling HC use
Managed by MCOs (agreements with providers to offer services at reduced )
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

Health Care Reform in US

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
  - 50% increase by 2060
- 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

face # of problems: increased burden, lack privacy, demands of time and energy
need for personal care and paying long term care services projected to increase
National Family Caregiver Support Program
Support for working caregivers is growing concern

Preventing Disease and Disability in Old Age

Immunization against pneumonia and flu
Medications
- elderly take drugs for many conditions
- metabolize drugs less actively
- risk drug interactions higher
Osteoporosis
- increase risk for broken bones leading to disability
- common in women
  - exacerbated by bone loss being greatest in years after menopause
- risk increased by smoking/alcohol consumption
Falls
- many risk factors for old
- result serious injury 1/10 times
- risk factors are use of 4+ meds
Impairment of vision and hearing
- sensory loss leading to social isolation
- glaucoma, diabetic retinopathy, macular degeneration, cataracts from exposure to sun
- hearing loss from exposure to noise
Oral health
- tooth loss, periodontal disease, etc.
- lead to social isolation
Medicare doesn’t cover dental, eyeglasses, or hearing aids

Alzheimer’s and Other Dementias

Risk increases with increasing age
tremendous burden carried by caregivers
- dementia LTC costs 300 billion/year
- delaying onset by few years SUBSTANTIALLY reduces $ and personal burden
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