Healthcare Delivery and Community Medicine - Lecture 1 Notes

Medical Care vs. Health Care

• Medical Care:
  • Provided by a physician.
  • Restricted in scope.
  • Focuses on pathophysiological and social problems.
  • Strong element of caring (direct one-on-one relationship).
• Health Care:
  • Three parts:
    • Personal health care
    • Community health care
    • Combined services

Personal Health Care

• Services dealing directly with individuals for health maintenance or cure of illness.
• Not necessarily a one-on-one relationship.
• Example: Health Act (Helping Ensure Life and Lifesaving Access to Podiatric Physicians).
  • Ensured access to foot health for Medicaid beneficiaries.
  • Amended the definition of physicians in Title 19 of the Social Security Act to recognize podiatrists as physicians.
  • Title 19 = Medicaid.
  • Clarifications to the Medicare therapeutic shoe program for persons with diabetes.
  • Helped prevent foot ulceration and amputations among high-risk individuals.
  • Preventative approach.

Community Health Care

• Services directed towards population groups.
• Examples:
  • Pure drinking water.
  • Sanitary sewage disposal.
  • Solid waste disposal.
  • Fluoridation of water.
  • Control of air and noise pollution.
  • Control of food, milk, and drugs.
• Example: Flint, Michigan lead in water crisis.
  • Cleaning up the water is an example of community health care.

Combined Services

• Services including aspects of both personal and community health services.
• Examples:
  • Mass immunization programs.
    • Protects the immunized individual and prevents spread in the community.
  • Tuberculosis and venereal disease case findings.
    • Treating infected individuals and their contacts prevents disease spread.
  • Mass COVID-19 testing and immunization.

Overview of the Health Services System in The United States

• Before 1850: No organized health measures.
  • Loose collection of independent health services.
• Mid-19th century: Modern health care system began.
• Examples of practices at that time:
  • Cigarettes containing atropine for bronchodilation.
  • Coca-Cola syrup (without cocaine) as a stimulant for exhaustion, neuralgia, sleeplessness, and despondency.

Periods of Development of the American Health Care System

1. Institutionalization of Health Care (1850s)

• First large hospitals: Bellevue Hospital in New York City and Massachusetts General Hospital in Boston.
• First visible signs of organized health care services.
• First ambulance: Horse-drawn ambulance at Bellevue Hospital in 1869.

2. Introduction of the Scientific Method into Medicine (1900)

• Science began entering medicine.
• Opening of Johns Hopkins University in Baltimore.
• American medical education was in chaos; most medical schools were like trade schools.
• Johns Hopkins ushered in a new era:
  • Rigid entrance requirements for medical students.
  • Upgraded medical school curriculum with emphasis on the scientific method.
  • Incorporation of bedside teaching and laboratory research.
  • Integration of the school of medicine with the hospital through joint appointments.

3. Growing Interest in the Social and Organizational Structure of Health Care (1940s)

• Financing of health care and more federal government involvement.
• First insurance plans: Blue Cross and Blue Shield.
• Hill-Burton Act (Hospital Survey and Construction Act of 1946).
  • Helped communities construct hospitals and other health facilities.
  • Provided matching federal grants to supplement community funds.
• National Institutes of Health (NIH).
  • Provided large research budgets.
  • Contributed to medical technology and assessment.
  • Sponsored clinical trials.
  • Conducted consensus development conferences.
• Medicare (Title 18 of the Social Security Act of 1965).
  • Federally sponsored and supervised program.
  • Initially for those 65 and over but expanded today.
  • Principle of healthcare as a right, not a privilege.

4. Limited Resources, Restriction of Growth, and Reorganization of Financing and Delivering Care (1980s)

• Limits of resources were being approached due to unrestricted growth and spending.
• Reimbursement policies introduced into Medicare to decrease unrestricted growth.
• Employer-controlled insurance systems caused a decrease in inpatient days.
• Reduction in the operating size of many hospitals.
• Experts claimed a major surplus of physicians, and medical schools were asked to produce less.
• Pressure to stop spending, reduce size, use less, and reduce expenditures.
• Appearance of HMOs to decrease growth and spending.

Predominant Health Problems in the American Health Care System - Historical Phases

1. 1850s - 1900s: Epidemics of Acute Infectious Diseases

• Diseases affecting population groups, not just individuals.
• Related to impure food, contaminated water supply, inadequate sewage, and poor urban housing.
• Cholera outbreak in New York (spread to Boston in 1848).
  • Bacterial disease spread through water.
• Typhoid: Bacterial disease from ingestion of food or water contaminated with feces.
• Dysentery: Viral, bacterial, or parasitic infestation from contaminated food, water, or objects.

2. Early 1900s: Transition to Individual Health Problems

• Epidemics of acute infectious disease had been brought under control due to improving environmental conditions.
  • Cities developed systems to purify water and sanitary disposal of sewage.
  • Safeguarding the quality of milk and food and even drugs monitoring the quality of urban housing.
  • Health departments began to grow.
• Health problems affected individuals rather than population groups.
• Acute events, infectious or traumatic, required individualized attention.
• 1922: Insulin to treat diabetes.
• Top diseases: Pneumonia, influenza, tuberculosis, heart disease, nephritis, accidents.

3. 1950s: Chronic Diseases and Longer Lifespans

• Medical science advances: Better surgical techniques, better diagnostics.
• Growth of hospitals and medical schools.
• Advances: Penicillin, surgery and obstetrics, treatment for pneumonia and pernicious anemia.
• Acute diseases became more manageable; individuals lived longer.
• Manifestation of long-term chronic diseases.
• Heart disease, cancer, and stroke accounted for about 66% of all deaths.

4. Disease Patterns - 2002-2017

• Heart disease, cancer, and cerebrovascular disease remained the top three causes of death.
• Chronic lower respiratory diseases followed.
• Accidents also remained on the list.

Medical error consideration

• Medical malpractice might be the third leading cause of death in the US.
• Up to 21% of patients receive some form of negative care.
• CDC is not counting medical malpractice when they look at the top causes of death.

Global comparison

• Heart disease and stroke are also among the leading causes of death globally.
• Cancer is missing from the global top 10 causes of death list.
• Road injuries are included in global but not national listings.

Disability

• In the 1950s, arthritis was the number one cause of disability, followed by blindness and arteriosclerosis.
• In 2009, 22.2% of Americans over 18 (about 50 million people) suffered from arthritis.
• Musculoskeletal and connective tissue diseases were leading causes of disability in 2010-2013.

Predominant Health Problems in the Future (1980s onwards)

• Chronic illnesses related to genetic makeup, lifestyle, and environmental hazards will predominate.

Health impacts of Coke

• First 10 minutes: $10$ teaspoons of sugar hit your system, $100\%$ of the recommended daily intake. Phosphoric acid cuts the flavor to avoid vomiting.
• 20 minutes: Blood sugar spikes, causing an insulin burst. The liver turns sugar into fat.
• 40 minutes: Caffeine absorption is complete, pupils dilate, blood pressure rises. Liver dumps more sugar into the bloodstream. Adenosine receptors in the brain are blocked preventing drowsiness.
• 45 minutes: Body helps your dopamine production, stimulating pleasure centers of your brain
• 60 minutes: Phosphoric acid binds calcium, magnesium, and zinc, providing a further boost of in metabolism, and this is compounded by high doses of sugar and artificial sweeteners, also increasing the urinary excretion of calcium. Then comes a sugar crash.

Disease Pattern Summary

• 1850s-1900s: Epidemics of acute infections.
• Early 1900s: Individual acute conditions.
• 1950s: General chronic illnesses.
• 1980s-Present: Special chronic illnesses.

Prevention and Treatment

• Acute Infections:
  • Clear-cut beginning, middle, and end.
  • Treated with one-shot solutions.
  • Examples:
    • Reconstruction of sewage treatment eliminates bad water supply contamination.
    • Polio vaccine can protect an entire population.
    • Urinary tract infection treated with antibiotics.
• Chronic Illness:
  • Prevention must be long-term and continuous.
  • Aimed at major changes in individual knowledge, values, and behavior patterns.
  • Lifestyle changes.
• Changes in disease patterns require different services and interventions.
• COVID-19 pandemic is a case in point.

Definition Break

• Endemic: Condition that persists within a geographical area.
  • Baseline level of a disease.
• Epidemic: Condition from a common cause affecting a large number of people.
  • Community-wide or state-wide outbreak.
  • Increase in cases above what is normally expected.
• Outbreak: Same as epidemic but often for a more limited geographic area.
• Pandemic: Spread of disease over considerable areas (nationwide, continent-wide, or worldwide).
  • Epidemic that has spread over several countries or continents.
  • COVID-19 = pandemic.

Technology in American Healthcare

Historical Change

• 1850s-1900s: Little technology available.
  • No scientific basis to medicine.
  • Few effective treatments.
  • Poorly trained physicians (apprenticeships or short courses).
  • Medical care limited to what was in their little black bags.
  • Poorly trained nurses (religious groups or poor women).
  • First formal training for nurses in 1860 (Bellevue Hospital).
  • Hospitals were unsanitary, crowded, and disease-ridden (threat to life).
• 1900s-1940s: Changes in US and Europe, Discoveries from research laboratories within medical schools and hospitals brought science into medicine
  • Safer and easier diagnosis and treatment
  • 1910: Abraham Flexner. Carnegie Foundation study. Training of physicians needed to be done in the universities, and that training should be based on science.
  • Physicians begin to be trained as scientists and spend time in their patient's homes and off and in their offices, but they also begin to start begin to start taking their more ill patients to the hospitals for care.
  • Specialization at that time. Mostly general practitioners, with some specialists that make up 20% of all doctors.
  • Hospitals begin to play a major role as the physicians begin to bring ill patients into the hospital.
• World War II (1939-1945):
  • Advances in research and more government control.
  • Development of antibiotics and new surgical techniques for trauma and burns.
  • New approaches to transportation and new procedures, new equipment within medical facilities.
  • Scientific knowledge required specialization.
  • Before war $80\%$ G.P., following war $80\%$ Specialists.

Technology Today

• Advanced incredibly, but problems exist.
  • Technology adopted without appropriate evaluation of effectiveness.
  • Limited examination of cost implications.
  • American Health Services system has been captured by technology.
  • Use of technology even if it is not more effective.
• Students view excellence as technical advancements, perhaps becoming less personal
• New technology sometimes comes in to use and then goes back out of use.
• Large portions of society are not befitting from technology.

Social Organization for the Use of Technology (Historical)

• 1850s-1900s: No organized programs.
  • Hospitals started by religious groups for the impoverished.
  • Ethic: People should care for themselves; be grateful for charities.
• 1930s: Great Depression, Franklin Roosevelt's New Deal.
  • Social programs to repair the damage of the Depression.
  • Large-scale national programs to assist those who could not assist themselves.
  • Assumption of responsibility by the national government.
• World War II: Social expansion
  • Men and women receive a large array of health services simply by being in the military
  • Services provided without charge with salaried governmental workers/doctors
  • Services provided as a right not as a charity of military veterans
• Health Insurance:
  • Industry growth Health insurance plans, pension plans, disability plans increase
  • Blue Cross and Blue Shield
  • Commercial insurance companies
  • Medicare early 1960's

Systems of the American Health Care System

Medicare

• Federal program covering individuals aged 65+ and some disabled individuals.
• Single-payer program administered by the federal government.
• Financed by federal income taxes, a payroll tax shared by employers and employees, and individual enrollee premiums.
• Several parts:
  • Part A: Hospital insurance.
  • Part B: Medical insurance.
  • Part C: Medicare Advantage Plans (private insurance companies).
  • Part D: Prescription drug coverage.
• Medicare supplemental plans (Medigap) pay for out-of-pocket costs.
• Does not cover complete preventive care, routine dental, hearing or vision care, cosmetic surgery, acupuncture, and routine foot care (with exceptions).
• Seniors pay about 22% of their income for health care costs, despite Medicare coverage.

Medicaid

• Program for low-income and disabled individuals.
• Federal law requires coverage of very poor pregnant women, children, and their parents, elderly, and disabled.
• Childless adults are not covered.
• Administered by the states in the District of Columbia (51 different programs).
• Financed jointly by the states and the federal government through taxes Dollar is matched by the federal government, at least a $50\%$. The actual percentage might not be a $50\%$ guarantee.
• Offers a comprehensive set of benefits including prescription drugs.
• Reimburses so little that sometimes patients cannot find a doctor that accept it
• State Child Health Insurance Program (SCHIP).
  • Children whose families make too much money to qualify for Medicaid but too little to purchase private health insurance.
  • Similar administrative and financing structures to Medicaid.

VA Health Insurance System

• Veterans Health Administration.
• Federally administered program for veterans of the military.
• Largest single provider of health care services in the country.
• Funded by taxpayer dollars and offers affordable if not free care to veterans.
• Mission: Medical care, education, training, research, emergency management.
• Focuses on hospital, mental health, and long-term care.
• Administered in government-owned hospitals and clinics.
• Twenty-two geographically distributed veterans integrated service networks.

Military Medical Care System

• For active military personnel.
• Available, free of charge.
• Claimed to be well-organized, highly integrated, comprehensive, and covers preventive care.
• TRICARE finances and covers families, dependents, and retired military.

Employer Sponsored Insurance

• Hallmark of the US health care industry.
• Integrated delivery system.
• Health insurance provided by employers as part of the benefits package.
• Administered by private companies (for-profit and not-for-profit).
• Self-insured companies pay health care costs directly to insurance companies or doctors.
• Financed through employers (majority of premium) and employees.
• Benefits vary with specific health insurance plans

Private Non-Group or Individual Market

• Covers self-employed or retired individuals.
• Individuals unable to obtain insurance through their employer.
• Administered by private insurance companies.
• Individuals pay an insurance premium out of pocket.
• Benefits vary with specific health insurance plans.
• Risk depends on individual health status.

Financing the U.S. Health Care System

• Two streams of money:
  • Collection of money for health care (money in).
  • Reimbursement of health service providers (money out).
• Shared by private insurance companies and the government (payers).
• Multi-payer system.

Summary

• Individuals or businesses pay premiums to private insurance companies, which pay health service providers.
• Individuals pay directly out of pocket to health service providers.
• Individuals or businesses pay taxes to the government, which pays health service providers through Medicare, Medicaid, CHIP.

Causes and Characteristics of Health Services in The United States

Physiologic and Psychological Basis and Utilization

• We want to look at the physiologic and psychological basis of health disease and care seeking and the indicators and predictors of health services utilization
• Definitions:
  • Illness:
    • Individual's perception of the loss of functional capacity.
    • Rare experience that denotes both a physical and a social state.
    • Person's subjective experience of their symptoms.
  • Disease:
    • Professional definition of that pathologic process.
    • More precise.
    • Physician is the person giving the definition.
    • Vehicle of talking to a person who has the illness.
• It is illness, the individual's perception of that impaired function, that stimulates the patient to go seek medical care
• There is not a code for when an individual says, "I have a headache" or when they say, "I have a stomachache."

Pathophysiologic Process Involved in the Disease Production Include:

• Vascular: Affects multiple organ systems.
• Inflammation: Can be infectious, traumatic, or autoimmune.
• Neoplastic: Abnormal neural tissues.
• Toxic: Environmental pollutants.
• Metabolic: Due to hormone or nutrient disorders.
• Degeneration: Primary idiopathic disorder or secondary to another process such as aging.

Symptom Production/Pathologic Process

• A pathologic process may begin and exist silently for some time without any evidence of a physiologic alteration.
• A pathologic process may be present and discoverable by diagnostic tests long before it produces any sufficient symptoms for a patient to feel.
• Chronic diseases associated with aging and lifestyle have replaced infectious diseases as a major cause of disability.

Social and Cultural Influences on Disease and Behavior

• Seeking medical care may or may not be associated with a pathologic process.
• Social and cultural values greatly influence individual decisions to see a physician.
• It has been estimated that $70\%$ to $90\%$ of self-recognized illness is not treated in the conventional medical care delivery system

Influence of Supply

• Sometimes the structure and availability of health services contribute to the amount of care that is sought.
• Health provider diagnosis shapes the healthcare system.
• This is not exactly what happens.
• The use of medical services is the result of a unique interaction involving the pathologic process, the physicians are the patient perception and the availability of those services.

Indicators and Predictors of Health Services Utilization

• Type: Category of service rendered (physician's office, hospital, prescriptions).
• Purpose: Reason the care is being treated.
  • Primary Prevention: Health Maintenance in the absence of symptoms
  • Secondary Prevention: Diagnosis and treatment of an illness in the interest of a previous state of well-being
  • Tertiary Prevention: Rehabilitation or maintenance in the case of a long-term health problem
• Site: Place where services are received (inpatient or outpatient).
• Time intervals: Contact measures whether the service occurred during a certain period of time.
• Volume: Total number of services rendered during that period of time.
• Episodic patterns: Patterns of providers, referrals, continuity of care, the occurrence episode of that illness, doctor says there is probably a minor issue, versus a patient who requires blood work.
• Characteristics of the population
  • Predisposing Variables: Age, sex, race, ethnicity, education, lifestyle practices, beliefs
  • Enabling Variable's: Income and residents (Medicaid and Medicare).
  • Need Variables: Perceived need and evaluated need. The physician evaluated see that the situation is serious, they want to make sure, not for an individual to take things lightly