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The late-stage diagnosis of colorectal cancer: Health departments, for example, provide unique venues for the training of nurses, physicians, and other health care professionals in the basics of community-based health care and gain an understanding of population-level approaches to health improvement. Reduced use of laboratory testing prevents the analyses of pathogenic isolates needed for disease tracking, testing of new pathogens, and determining the levels of susceptibility to antimicrobial agents. Termination of Medi-Cal benefits: Rounded tips ensure that our gastrostomy tubes insert easily.

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Because of its history, structure, and particularly the highly competitive market in health services that has evolved since the collapse of health care reform efforts in the early s, the health care delivery system often does not interact effectively with other components of the public health system described in this report, in particular, the governmental public health agencies.

State health departments often have legal authority to regulate the entry of providers and purchasers of health care into the market and to set insurance reimbursement rates for public and, less often, private providers and purchasers.

They may control the ability of providers to acquire desired technology and perform complex, costly procedures that are important to the hospital but increase demands on state revenues.

Finally, virtually all states have the legal responsibility to. Many health care providers argue that such regulation adds to their costs, and high-profile problems can create additional tensions that impede collaboration between the state public health agency and the health care delivery system. Furthermore, when the delivery of health care through the private sector falters, the responsibility for providing some level of basic health care services to the poor and other special populations falls to governmental public health agencies as one of their essential public health services, as discussed in Chapter 1.

In many jurisdictions, this default is already occurring, consuming resources and impairing the ability of governmental public health agencies to perform other essential tasks. Drawing heavily on the work of other IOM committees, this chapter examines the influence that health insurance exerts on access to health care and on the range of care available, as well as the shortcomings in the quality of services provided, some of the constraints on the capacity of the health care system to provide high-quality care, and the need for better collaboration within the public health system, especially among governmental public health agencies and the organizations in the personal health care delivery system.

Health care is not the only, or even the strongest, determinant of health, but it is very important. For most Americans, having health insurance— under a private plan or through a publicly financed program—is a threshold requirement for routine access to health care. It is also associated with having a regular source of care and with greater and more appropriate use of health services. Private insurance is predominantly purchased through employment-based groups and to a lesser extent through individual policies Mills, Publicly funded insurance is provided primarily through seven government programs see Table 5—1.

Medicare provides coverage to Additionally, public funding supports directly. Because the largest public programs are directed to the aged, disabled, and low-income populations, they cover a disproportionate share of the chronically ill and disabled.

However, they are also enormously important for children. Being uninsured, although not the only barrier to obtaining health care, is by all indications the most significant one. Those without health insurance or without insurance for particular types of services face serious, sometimes insurmountable barriers to necessary and appropriate care. Adults without health insurance are far more likely to go without health care that they believe they need than are adults with health insurance of any kind Lurie et al.

Children without health insurance may be compromised in ways that will diminish their health and productivity throughout their lives. When individuals cannot access mainstream health care services, they often seek care from the so-called safety-net providers. These providers include institutions and professionals that by mandate or mission deliver a large amount of care to uninsured and other vulnerable populations.

People turn to safety-net providers for a variety of reasons: Safety-net providers are also more likely to offer outreach and enabling services e. Yet the public and many elected officials seem almost willfully ignorant of the magnitude, persistence, and implications of this problem. Surveys conducted over the past two decades show a consistent underestimation of the number of uninsured and of trends in insurance coverage over time Blendon et al.

The facts about uninsurance in America are sobering see Box 5—1. By almost any metric, uninsured adults suffer worse health status and live shorter lives than insured adults IOM, a. Because insurance status affects access to secure and continuous care, it also affects health, leading to an estimated 18, premature deaths annually IOM, a. Having a regular source of care improves chances of receiving personal preventive care and screening services and improves the management of chronic disease.

When risk factors, such as high blood pressure, can be identified and treated, the chances of developing conditions such as heart disease can be reduced. Similarly, if diseases can be detected and treated when they are still in their early stages, subsequent rates of morbidity and mortality can often be reduced. Without insurance, the chances of early detection and treatment of risk factors or disease are low. Forty-two million people in the United States lacked health insurance coverage in Mills, This number represented about 15 percent of the total population of million persons at that time and 17 percent of the population younger than 65 years of age; 10 million of the uninsured are children under the age of 18 about 14 percent of all children , and about 32 million are adults between the ages of 18 and 65 about 19 percent of all adults in this age group.

Nearly 3 out of every 10 Americans, more than 70 million people, lacked health insurance for at least a month over a month period. These numbers are greater than the combined populations of Texas, California, and Connecticut. More than 80 percent of uninsured children and adults under the age of 65 lived in working families. Contrary to popular belief, recent immigrants accounted for a relatively small proportion of the uninsured less than one in five.

Insurance status is a powerful determinant of access to care: Research consistently finds that persons without insurance are less likely to have any physician visits within a year, have fewer visits annually, and are less likely to have a regular source of care. Children without insurance are three times more likely than children with Medicaid coverage to have no regular source of care.

The uninsured were less likely to receive health care services, even for serious conditions. Research consistently finds that persons without insurance are less likely to have any physician visits within a year, have fewer visits annually, and are less likely to have a regular source of care 15 percent of uninsured children do not have a regular provider, whereas just 5 percent of children with Medicaid do not have a regular provider , and uninsured adults are more than three times as likely to lack a regular source of care.

However, even when the uninsured receive care, they fare less well than the insured. For example, Hadley and colleagues found that uninsured adult hospital inpatients had a significantly higher risk of dying in the hospital than their privately insured counterparts. Emergency and trauma care were also found to vary for insured and uninsured patients. Uninsured persons with traumatic injuries were less likely to be admitted to the hospital,.

For children, too, being uninsured tends to reduce access to health care and is associated with poorer health. Untreated ear infections, for example, can have permanent consequences of hearing loss or deafness. Many people who are counted as insured have very limited benefits and are exposed to high out-of-pocket expenses or service restrictions. Three areas in which benefits are frequently circumscribed under both public and private insurance plans are preventive services, behavioral health care treatment of mental illness and addictive disorders , and oral health care.

When offered, coverage for these services often carries limits that are unrelated to treatment needs and are stricter than those for other types of care King, Cost-sharing requirements for these services may also be higher than those for other commonly covered services. Access to care for the insured can also be affected by requirements for cost sharing and copayments. Cost sharing is an effective means to reduce the use of health care for trivial or self-limited conditions. Numerous studies, starting with the RAND Health Insurance Experiment, show that copayments also reduce the use of preventive and primary care services by the poor, although not by higher-income groups Solanki et al.

The same effects have been shown for the use of behavioral health care services Wells et al. Cost sharing may discourage early care seeking, impeding infectious disease surveillance, delaying timely diagnosis and treatment, and posing a threat to the health of the public. The committee encourages health care policy makers in the public and private sectors to reexamine these issues in light of the concerns about bioterrorism. This committee was not constituted to make specific recommendations about health insurance.

The issues are complex, and the failures of health. However, the committee finds that both the scale of the problem and the strong evidence of adverse health effects from being uninsured or underinsured make a compelling case that the health of the American people as a whole is compromised by the absence of insurance coverage for so many.

Assuring the health of the population in the twenty-first century requires finding a means to guarantee insurance coverage for every person living in this country. Adequate population health cannot be achieved without making comprehensive and affordable health care available to every person residing in the United States. It is the responsibility of the federal government to lead a national effort to examine the options available to achieve stable health care coverage of individuals and families and to assure the implementation of plans to achieve that result.

Absent the availability of health insurance, the role of the safety-net provider is critically important. Increasing their numbers and assuring their viability can, to some degree, improve the availability of care. That committee further identified core safety-net providers as having two distinguishing characteristics: The organization and delivery of safety-net services vary widely from state to state and community to community Baxter and Mechanic, The safety net consists of public hospital systems; academic health centers; community health centers or clinics funded by federal, state, and local governmental public health agencies see Chapter 3 ; and local health departments themselves although systematic data on the extent of health department services are lacking IOM, a.

A recent study of changes in the capacities and roles of local health departments as safety-net providers found, however, that more than a quarter of the health departments surveyed were the sole safety-net providers in their jurisdictions and that this was more likely to be the case in smaller jurisdictions Keane et al.

Services provided by state and local governments often include mental health hospitals and outpatient clinics, substance abuse treatment programs, maternal and child health services, and clinics for the homeless. In addition, an estimated 1, public hospitals nationwide Legnini et al. These demands can overwhelm the traditional population-oriented mission of the governmental public health agencies.

Furthermore, changes in the funding streams or reimbursement policies for any of these programs or increases in demand for free or subsidized care that inevitably occur in periods of economic downturn create crises for safety-net providers, including those operated by state and local governments see the section Collaboration with Governmental Public Health Agencies later in this chapter for additional discussion.

Intact but Endangered IOM, a: The convergence and potentially adverse consequences of these new and powerful dynamics lead the committee to be highly concerned about the future viability of the safety net. Although safety net providers have proven to be both resilient and resourceful, the committee believes that many providers may be unable to survive the current environment. Taken alone, the growth in Medicaid managed care enrollment; the retrenchment or elimination of key direct and indirect subsidies that providers have relied upon to help finance uncompensated care; and the continued growth in the number of uninsured people would make it difficult for many safety net providers to survive.

Taken together, these trends are beginning to place unparalleled strain on the health care safety net in many parts of the country. The committee believes that the effects of these combined forces and dynamics demand the immediate attention of public policy officials.

Intact but Endangered IOM, a , aimed at ensuring the continued viability of the health care safety net see Box 5—2. Federal and state policy makers should explicitly take into account and address the full impact both intended and unintended of changes in Medicaid policies on the viability of safety-net providers and the populations they serve.

All federal programs and policies targeted to support the safety net and the populations it serves should be reviewed for their effectiveness in meeting the needs of the uninsured. Given the growing number of uninsured people, the adverse effects of Medicaid managed care on safety-net provider revenues, and the absence of concerted public policies directed at increasing the rate of insurance coverage, the committee believes that a new targeted federal initiative should be established to help support core safety-net providers that care for a disproportionate number of uninsured and other vulnerable people.

The committee is concerned that the specific types of care that are important for population health—clinical preventive services, mental health care, treatment for substance abuse, and oral health care—are less available because of the current organization and financing of health care services. Many forms of publicly or privately purchased health insurance provide limited coverage, and sometimes no coverage, for these services.

The evidence that insurance makes a difference in health outcomes is well documented for preventive, screening, and chronic disease care IOM, b. Such services include immunizations and screening tests, as well as counseling aimed at changing the personal health behaviors of patients long before. The importance of counseling and behavioral interventions is evident, given the influence on health of factors such as tobacco, alcohol, and illicit drug use; unsafe sexual behavior; and lack of exercise and poor diets.

These risk behaviors are estimated to account for more than half of all premature deaths; smoking alone contributes to one out of five deaths McGinnis and Foege, Coverage of clinical preventive services has increased steadily over the past decade.

In , about three-quarters of adults with employment-based health insurance had a benefit package that included adult physical examinations. Two years later, the proportion had risen to 90 percent Rice et al.

The type of health plan is the most important predictor of coverage RWJF, Although the trend toward inclusion of clinical preventive services is positive, such benefits are still limited in scope and are not well correlated with evidence regarding the effectiveness of individual services. Public Health Service, has endorsed a core set of clinical preventive services for asymptomatic individuals with no known risk factors.

However, the USPSTF recommendations have had relatively little influence on the design of insurance benefits, and recommended counseling and screening services are often not covered and, consequently, not used Partnership for Prevention, see Box 5—3. As might be expected, though, adults without health insurance are the least likely to receive recommended preventive and screening services or to receive them at the recommended frequencies Ayanian et al. Having any health insurance, even without coverage for any preventive services, increases the probability that an individual will receive appropriate preventive care Hayward et al.

Studies of the use of preventive services by Hispanics and African Americans find that health insurance is strongly associated with the increased receipt of preventive services Solis et al.

However, the higher rates of uninsurance among racial and ethnic minorities contribute significantly. Counseling to address serious health risks—tobacco use, physical inactivity, risky drinking, poor nutrition—is least likely to be covered by an employer-sponsored health plan. Yet about half of all pregnancies and nearly a third of all births each year are unintended. One out of five employer-sponsored plans does not cover childhood immunizations, and one out of four does not cover adolescent immunizations although these are among the most cost-effective preventive services.

For example, African Americans and members of other minority groups who are diagnosed with cancer are more likely to be diagnosed at advanced stages of disease than are whites Farley and Flannery, ; Mandelblatt et al.

Preventive services are important for older adults, for whom they can reduce premature morbidity and mortality, help preserve function, and enhance quality of life. Unfortunately, the Medicare program was not designed with a focus on prevention, and the process for adding preventive services to the Medicare benefit package is complex and difficult. Unlike forms of treatment that are incorporated into the payment system on a relatively routine basis as they come into general use, preventive services are subject to a greater degree of scrutiny and a demand for a higher level of effectiveness, and there is no routine process for making such assessments.

Box 5—4 lists the preventive services currently covered by Medicare. The level of use of preventive services among older adults has been relatively low CDC, For individuals with Medicare, the following services are covered by Medicare Part B:. Diabetes services coverage of self-management training and glucose monitoring supplies for people with diabetes. Outpatient nutrition counseling by registered dietitians for patients with diabetes and some types of kidney disease. Cardiovascular disease and diabetes exemplify the problem.

Although cardiovascular disease is the leading cause of death and diabetes is one of the most significant chronic diseases affecting Medicare beneficiaries, physicians cannot screen for lipids disorders or diabetes unless the patient agrees to pay out-of-pocket for the tests.

Medicaid benefits vary by state in terms of both the individuals who are eligible for coverage and the actual services for which coverage is provided. The exception is preventive services for children.

In , the U. This entitled poor children to a comprehensive package of preventive health care and medically necessary diagnostic and treatment services. However, some studies have demonstrated that EPSDT has never been fully implemented, and the percentage of children receiving preventive care through it remains low for reasons ranging from.

Additionally, data show that as many as 50 percent of children who have an EPSDT visit are identified as requiring medical attention, but if they are referred for follow-up care, only one-third to two-thirds go for their referral visit Rosenbach and Gavin, Data for children are less reliable, but the overall prevalence of mental disorders is also estimated to be about 20 percent DHHS, Mental disorders are a major public health issue because they affect such a large proportion of the population, have implications for other health problems, and impose high costs, both financial and emotional, on affected individuals and their families.

For the most prevalent mental health disorders such as depression and anxiety, receipt of appropriate care is associated with improved functional outcomes at 2 years Sturm et al. Access to care is constrained by limitations on insurance coverage that are greater than those imposed for other diseases.

Annual and lifetime coverage limits are frequently less, and mental health coverage often has more hidden costs in the forms of copayments and higher deductibles Zuvekas et al. Table 5—2 shows the distribution of sources of payment for treatment for mental health and addictive disorders in Additionally, those with no insurance all year paid nearly 60 percent of costs out-of-pocket, whereas those with some private insurance paid 40 percent of costs out-of-pocket in Zuvekas, Number of eligible children.

The number of eligible children fell by more than half a million between and The medical screening rate is not adjusted according to the federal periodicity schedule or the average period of eligibility, but instead reports the percentage of children who were eligible for any period of time during fiscal year and who received one or more medical screens.

Young children were significantly more likely to be screened: The participant rate—the number of children screened compared to the number of children expected to be screened, based on the federal periodicity schedule and the average period of eligibility—increased from 51 percent in to 56 percent in In , the Health Care Financing Administration established a participant rate goal of 80 percent, to be achieved by fiscal year As of fiscal year , only nine states reported meeting or exceeding the federally established goal.

About 40 million people more than one in five ages 18 to 64 are estimated to have a single mental disorder of any severity or both a mental and an addictive disorder in a given year Regier et al. The most common conditions fall into the broad categories of schizophrenia, affective disorders including major depression and bipolar or manic-depressive illness , and anxiety disorders e. Schizophrenia affects at least an estimated 2 million Americans in any year Regier et al. Manic-depressive illness is reported to exist in 1 percent of adults.

Only 25 percent of people who have a mental disorder obtain diagnosis and treatment from the health care system, in contrast to 60 to 80 percent of those with heart disease DHHS, a. Evidence-based practice guidelines for depression endorse antidepressant medications and cognitive-behavioral or interpersonal psychotherapies AHCPR, ; Department of Veterans Affairs, ; Schulberg et al.

Recent studies have shown impressive results for treatment of depression in primary care settings Sturm and Wells, ; Schoenbaum et al. The provision of such services is cost-effective and comparable to the cost-effectiveness of other common procedures. However, reimbursement policies for primary care do not support the services necessary to provide evidence-based care for depression Wells et al.

Adults with either no insurance coverage or coverage that excludes or limits extended treatment of mental illness receive less appropriate care and may experience delays in receiving services until they gain public insurance Rabinowitz et al. Adults with mental disorders are also more likely to lose health insurance coverage within a year following their diagnosis than those without a mental disorder Sturm and Wells, The limited and unstable nature of insurance for treatment of mental illness has several implications for governmental public health agencies because the severely mentally ill are likely to end up receiving care in publicly funded safety-net programs Rabinowitz et al.

Funding to support the public mental health system comes from reimbursements for. Taken in the aggregate, these funding streams are neither adequate nor reliable enough to meet the needs of individuals with serious mental disorders IOM, a.

As with other forms of safety-net care, the urgency of providing treatment to the severely mentally ill erodes funds available for prevention purposes. In the United States, more than 18 million people who use alcohol and nearly 5 million who use illicit drugs need substance abuse treatment SAMHSA, Substance abuse, like mental illness, exacts enormous social costs across all segments of society.

Most recipients 87 percent of specialty treatment for alcohol or drug abuse receive it in outpatient settings RWJF, , but overall, less than one-fourth of those who need treatment get it. Barriers to treatment include stigma, lack of available treatment facilities, unwillingness to admit that treatment is needed, and inability to pay for care.

Public sources provide more than two-thirds of the funding for alcohol and drug treatment facilities. Half of such funds come from dedicated funding at the federal, state, and local levels in the form of various block grants to state safety-net programs. Medicaid and Medicare cover 21 percent of treatment, private insurance covers 14 percent, and 10 percent is paid directly by patients as out-of-pocket costs.

Another 5 percent is covered through various charitable sources. Insurance policies held by many individuals constrain the use of substance abuse services by the exclusion of benefits for such services and by the use of annual and lifetime limits on benefits and other controls on service utilization. Between and , private insurance for substance abuse services fell 0. Over the same period, out-of-pocket payments for specific types of substance abuse treatment increased Coffey et al.

However, the high out-of-pocket costs faced by individuals who pay for their own treatment discourage many who need care from seeking it. Like mental illness and addiction disorders, oral health has been neglected in the health care delivery system.

The consequences in terms of individual and population health are significant—oral health is a matter of public health concern because it affects a large proportion of the population and is linked with overall health status see Box 5—7. The effects of oral diseases are cumulative and influence aspects of life as fundamental as the foods people can eat, their ability to communicate effectively, and their social acceptability.

The problems in the way the health care delivery system relates to oral health include lack of dental coverage and low coverage payments, the separation of medicine and dentistry in training and practice, and the high proportion of the population that lacks any dental insurance. The committee focused on the problem of insurance and access to care. According to the Department of Health and Human Services DHHS Office of Health Promotion and Disease Prevention, more than million Americans have limited or no dental insurance, nearly four times the number who lack insurance for medical care cited by Allukian, As with other types of health services, insurance is a strong predictor of access to and use of dental services, and minorities and low-income populations are much less likely to have dental insurance or to receive dental care.

Individuals and families living below the poverty level experience more dental decay than higher-income groups, and their cavities are less likely to be treated GAO, More than a third of poor children ages 2 to 9 have one or more primary teeth with untreated decay, compared with Mexican-American adults and children are more likely to have untreated decayed teeth than any other.

When people think about the components of good health, they often forget about the importance of good oral health. This oversight is often reflected by health insurance coverage restrictions that exclude oral health care.

Oral health is important because the condition of the mouth is often indicative of the condition of the body as a whole. More than 90 percent of systemic diseases have oral manifestations. These diseases include immune deficiency e. Also, poor oral health can lead to poor general health. Infections in the mouth can enter the bloodstream and affect the functioning of major organs e. Poor oral care can also contribute to oral cancer, and untreated tooth decay can lead to tooth abscess, tooth loss, and—in the worst cases—serious destruction of the jawbone Meadows, For these reasons, oral health must recognized as an important component of assuring individual and population health.

The awareness that the mouth may be a mirror to the body can help to prevent illness, diagnose serious conditions early, and maintain optimum overall health Glick, Poor Mexican-American children ages 2 to 9 have the highest proportion of untreated decayed teeth The pattern for adults is similar DHHS, b: Medicare excludes coverage of routine dental care, and many state Medicaid programs do not provide dental coverage for eligible children or adults.

According to a report of the Surgeon General, fewer than one in five Medicaid-covered children received a single dental visit in a recent year-long study period DHHS, b. Low-income Hispanic children and adults are less likely to be eligible for Medicaid than other groups, so even the limited Medicaid benefits are unlikely to be available to them. The committee found that preventive, oral health, mental health, and substance abuse treatment services must be considered part of the comprehensive spectrum of care necessary to help assure maximum health.

Therefore, the committee recommends that all public and privately funded insurance plans include age-appropriate preventive services as recommended by. Preventive Services Task Force and provide evidence-based coverage of oral health, mental health, and substance abuse treatment services. Crossing the Quality Chasm IOM, b examined health system failures that compromise the quality of care provided to all Americans. As noted, it is often the responsibility of state departments of health to monitor providers and levy sanctions when quality problems are identified.

This adds to potential tensions with the public health system. Two particular quality problems have special significance in terms of assuring the health of the population: As the American population grows both older and more racially and ethnically diverse and as rates of chronic disease increase, important vulnerabilities in the health care delivery system are compromising individual and population health Murray and Lopez, ; Hetzel and Smith, Evidence shows that racial and ethnic minorities do not receive the same quality of care afforded white Americans.

These findings are consistent across a range of illnesses and health care services and remain even after adjustment for socioeconomic differences and other factors that are related to access to health care IOM, b. Furthermore, poor-quality health care is an important independent variable contributing to lower health status for minorities IOM, b. For example, racial differences in cervical cancer deaths have increased over time, despite the greater use of screening tests by minority women Mitchell and McCormack, The lower quality of care also compounds the adverse health effects of other disadvantages faced by minorities, including lower incomes and education, less healthy living environments, and a greater likelihood of being uninsured.

As discussed in Unequal Treatment IOM, b , the factors that may produce disparities in health care include the role of bias, discrimination, and stereotyping at the individual provider and patient , institution, and. The report found that aspects of the health care system—its organization, financing, and availability of services—may have adverse effects specifically for racial and ethnic minorities.

For example, time pressures on physicians hamper their ability to accurately assess presenting symptoms, especially when cultural or language barriers are present. Nearly 14 million people in the United States are not proficient in English.

Changes in the financing and delivery of health care services, such as the emphasis on cost controls and the almost complete conversion to managed care for the delivery of services under Medicaid, may be especially problematic for racial and ethnic minorities.

The disruption of traditional community-based care and the displacement of providers who are familiar with the language, culture, and values of ethnic communities create barriers to effective care Leigh et al. Such plans are characterized by higher per capita resource constraints and stricter limits on covered services Phillips et al. Fragmentation of health plans along socioeconomic lines engenders different clinical cultures, with different practice norms Bloche, The committee encourages the health care system and policy makers in the public and private sectors to give careful consideration to the interventions that are identified in Unequal Treatment IOM, b and aimed at eliminating racial and ethnic disparities in health care see Box 5—8.

Americans now live longer. A child born today can expect to live more than 75 years, and advances in medicine have also extended the life spans of earlier generations.

As detailed in Chapter 1 , the result is that individuals over age 65 constitute an increasingly large proportion of the U. Embedded in these demographic changes is a dramatic increase in the prevalence of chronic conditions. Chronic conditions, defined as illnesses that last longer than 3 months and that are not self-limiting, affect nearly half of the U. An estimated million Americans have one or more chronic conditions, and that number is estimated to reach million by Pew Environmental Health Commission, Nearly half of those with a chronic illness have more than one such condition IOM, a.

Additionally, disabling chronic conditions affect all age groups, but about two-thirds are found in individuals over age With the projected growth in the number of people over age 65 increasing from 13 percent of the.

Strengthen the stability of patient—provider relationships in publicly funded health plans. Increase the proportion of underrepresented U. Apply the same managed care protections to publicly funded health maintenance organization HMO enrollees that apply to private HMO enrollees.

Promote the consistency and equity of care through the use of evidence-based guidelines. Structure payment systems to ensure an adequate supply of services to minority patients and limit provider incentives that may promote disparities. Enhance patient—provider communications and trust by providing financial incentives for practices that reduce barriers and encourage evidence-based practice.

Integrate cross-cultural education into the training of all current and future health care professionals. The current health care system does not meet the challenge of providing clinically appropriate and cost-effective care for the chronically ill. Wagner and colleagues identified five elements required to improve outcomes for chronically ill patients:. Reorganization of practices to meet the needs of patients who require more time, a broad array of resources, and closer follow-up.

The health care delivery system as it exists today cannot deliver those elements. Recent surveys have found that less than half of U. Delivery of high-quality care to chronically ill patients is especially challenging in a decentralized and fragmented system, characterized by small practices AMA, Smaller practices have great difficulty in organizing the array of services and support needed to efficiently manage chronic disease.

The result is poor disease management and a high level of wasted resources. As the proportion of old and very old increases, the system-wide impact in terms of cost and increased disability may well overwhelm the human and financial resources available to care for chronically ill patients.

The resources of the health care delivery system are not balanced well enough to provide patient-centered care, to address the complex health care demands of an aging population, to absorb normal spikes in demand for urgent care, and to manage a large-scale emergency such as that posed by a terrorist attack. The relentless focus on controlling costs over the past decade has squeezed a great deal of excess capacity out of the health care system, particularly the hospital system.

It has also reduced the time that physicians spend with patients and the quality of the clinical encounter. At the same time, the design of insurance plans in both the public and the private sectors does not support the integrated disease management protocols needed to treat chronic disease or the data gathering and analysis needed for both disease management and population-level health.

The committee took special note of certain shortages of health care professionals, because these shortages are having a significant adverse effect on the quality of health care.

However, the focus on these two health care professional shortage areas does not suggest the absence of problems in other fields. Acute shortages of primary care physicians exist in many geographic areas, in certain medical specialties, and in disciplines such as pharmacy and dentistry, to name two.

In addition, a growing consensus suggests that major reforms are needed in the education and training of all health professionals. To deliver the type of health care envisioned in Crossing the Quality Chasm IOM, b , health care professionals must be trained to work in teams, to utilize information technology effectively, and to develop the competencies necessary to deliver care to an increasingly diverse population.

Health professions education is not currently organized to produce these results. In , 9 percent of physicians and Among physicians, about 3 percent are African American, 2. The severe underrepresentation of racial and ethnic minorities in the health professions affects access to care for minority populations, the quality of care they receive, and the level of confidence that minority patients have in the health care system.

A consistent body of research indicates that African-American and Hispanic physicians are more likely to provide services in minority and underserved communities and are more likely to treat patients who are poor, Medicaid eligible, and sicker IOM, c. Some studies indicate that, on average, minority physicians treat four to five times more minority patients than do white physicians, and studies of recent minority medical. Although more research is needed to examine the impact of minority health care professionals on the level of access and quality of care, for some minority patients, having a minority physician results in better communication, greater patient satisfaction with care, and greater use of preventive services IOM, b.

Although evidence has not established that increasing the numbers of minority physicians or improving cultural competence per se influences patient outcomes, existing research supports clear policies to increase the proportion of medical students drawn from minority groups.

RNs work in a variety of settings, ranging from governmental public health agency clinics to hospitals and nursing homes. The majority, however, work in hospitals, although the proportion dropped from 68 percent in to 59 percent in Spratley et al. Hospitals are facing shortages of RNs, in addition to shortages of pharmacists, laboratory technologists, and radiological technologists.

A recent national hospital survey AHA, b found that of , vacant positions, , were for RN positions. Hospital vacancy rates for RN positions averaged 11 percent across the country, ranging from about 10 percent to more than 20 percent in some states.

Nationally, more than one in seven hospitals report a severe shortage of RNs, with more than 20 percent of RN positions vacant. In general, hospitals in rural areas report the highest percentage of vacant positions.

The current shortage of RNs, particularly for hospital practice, is a matter of national concern because nursing care is critical to the operation and quality of care in hospitals Aiken et al. In a study analyzing more than 5 million patient discharges from hospitals in 11 states, Needleman and colleagues consistently found that higher RN staffing levels were associated with a 3 to 12 percent reduction in indicators—including lower rates of urinary tract infections, pneumonia, shock, and upper gastrointestinal bleeding and shorter lengths of stay—that reflect better inpatient care.

The shortage of hospital-based nurses reflects several factors, including the aging of the population, declining nursing school enrollment numbers Sherer, , the aging of the nursing workforce the average age increased from Furthermore, nurses have available other professional opportunities, and women, who once formed the bulk of the nursing workforce, now have alternate career prospects.

These trends do not appear to be a temporary, cyclical phenomenon. The aging of the population means an increase in the. Although some of this increase is to be expected because of the overall aging of the U. An aging workforce may have implications for patient care if older RNs have less ability to perform certain physical tasks HRSA, The shortage of RNs poses a serious threat to the health care delivery system, and to hospitals in particular. Hospitals contribute in various ways to assuring the health of the public, particularly by providing acute care services, educating health professionals, serving as a site for research, organizing community health promotion and disease prevention activities, and acting as safety-net providers.

However, hospitals play a uniquely important role by serving as the primary source of emergency and highly specialized care such as that in intensive care units ICUs and centers for cardiac care and burn treatment.

Recent changes in the structure of the hospital industry, the reimbursement of hospitals by public- and private-sector insurance programs, and nursing shortages have raised questions about the ability of hospitals to carry out these roles.

During the s, the spread of managed care practices contributed to reductions in overall hospital admissions, in the length of hospital stays, and in emergency department visits. As a result of decreasing demand for hospital services and a changing financial environment, hospitals in many parts of the country reduced the number of patient beds, eliminated certain services, or even closed McManus, The American Hospital Association AHA, a reports that from to , the number of emergency departments in the nation decreased by 8.

Over the same period, medical and surgical bed capacities were reduced by Although these reductions may have improved the efficiencies of hospitals, they have important implications for the capacity of the health care system to respond to public health emergencies. According to the American Hospital Association a , the demand for emergency department care increased by 15 percent between and In a random survey of emergency department directors in and , 91 percent of the respondents reported overcrowding problems Derlet et al.

The overcrowding was severe, resulting in delays in testing and treatment that compromised patient outcomes. The emergency departments of hospitals in many areas of New York City routinely operated at percent capacity Brewster et al. Patients regularly spent significant portions of their admission on gurneys in a hallway. One consequence of this crowding is the periodic closure of emergency departments and the diversion of ambulances to other facilities.

Ambulance diversions have been found to impede access to emergency services in metropolitan areas in at least 22 states U. House of Representatives, ; at least 75 million Americans are estimated to reside in areas affected by ambulance diversions.

Looking at 12 communities, Brewster and colleagues found that on average in , two hospitals in Boston closed their emergency departments each day and the Cleveland Clinic emergency departments were closed to patients arriving by ambulance for an average of nearly 12 hours a day.

The increase in demand for emergency care is attributed to several factors Brewster et al. In particular, managed care rules have changed to allow increased coverage of care provided in emergency departments.

Hospitals are in better compliance with the federal Emergency Medical Treatment and Labor Act, which requires emergency departments to treat patients without regard for their ability to pay. The adequacy of hospital capacity cannot be assessed without considering the system inefficiencies that characterize current insurance and care delivery arrangements.

These include the demands placed on hospital emergency and outpatient departments by the uninsured and those without access to a primary care provider. The unique characteristic of primary care is the role it plays as a regular or usual source of care for patients and their families. Good primary care assures continuity for the patient across levels of care, comprehensiveness of services according to the level of health or illness, and better coordination of these services over time Starfield, Defining the right level of immediate and standby capacity for emergency and inpatient care depends in part on the adequacy and effectiveness of general outpatient and primary care.

For example, chronic conditions like asthma and diabetes often can be managed effectively on an outpatient basis, but if the conditions are poorly managed by patients or their health care providers, emergency or inpatient care may be necessary. Billings and colleagues demonstrated strong links between hospital admission rates for such conditions and the socioeconomic and insurance status of the population in an area.

For example, admission rates for asthma were 6. Differences in disease prevalence accounted for only a small portion of the differences in hospitalization rates among low- and high-income areas. Although Billings and colleagues did not draw conclusions about the causal pathways leading to these higher admission rates, it is likely that the contributing factors include those discussed in this chapter, such as a lack of insurance or a regular source of care and the assignment of Medicaid populations to lower-cost health plans.

Geographically, areas with higher primary care physician-to-population ratios experience lower total health care costs Welch et al. Additionally, there is evidence that primary care is associated with reduced disparities in health; areas of high income inequality that also had good primary care were less likely to report fair or poor self-rated health Starfield, The link between the availability of primary care and better health is also supported by international evidence, which shows that nations that value primary care are likely to have lower mortality rates all causes; all causes, premature; and cause specific , even when controlling for macro- and micro-level characteristics e.

Although Billings and colleagues focused on the preventable demands for hospital care among low-income and uninsured populations, Closing the Quality Chasm IOM, b makes clear that the misuse of services also characterizes disease management among insured chronically ill patients.

In the early s, managed care became a common feature of the health care delivery system in the United States. In theory, managed care offers the promise of a population-based approach that can emphasize regular preventive care and other services aimed at keeping a defined group as healthy as possible.

These benefits are most easily achieved under a fully capitated, group practice model: For the patient, the model provides comprehensive care, an emphasis on prevention, and low out-of-pocket costs. Kaiser Permanente Medical Group pioneered the model more than 50 years ago on the basis of early experiences providing health care programs for employees of Kaiser industrial. An important opportunity was lost when insurance companies, health plans and health providers, and the state and federal governments saw managed care primarily as a cost-containment mechanism rather than a population-based approach to delivering comprehensive and effective health care services.

Reimbursement rate reductions, restrictions on care and choice of physician, and other aspects of plan management disaffected millions of Americans from the basic concept of managed care.

Furthermore, rapid turnover in enrollment, particularly in Medicaid managed care, ruined economic incentives for plans to view their enrollees as a long-term investment. This loss of trust in the idea of managed care is also the loss of a great opportunity to improve quality and restrain costs.

Loosely affiliated physician networks have no ability to identify their populations and develop programs specifically based on the epidemiology of the defined group. There is little ability to use data systems, shared protocols, or peer pressure to improve quality and reduce variations in health care practices. Managed care is undergoing rapid changes, some of which are likely to further undermine its viability.

Consumer demands for more choice and greater flexibility are weakening restrictions on access to providers and limitations on services.

Physicians are proving more aggressive and successful in their negotiations with plans to decrease constraints, and to date, most employers have been willing to accept the higher costs that result.

Employer acceptance may change in the face of double-digit insurance premium increases. Predicting the next configuration of insurance and plan delivery systems is dangerous in a system undergoing such rapid transition. A number of major insurance plans have announced that they will begin to offer defined-contribution options.

Consumers will be expected to shop for their own care with a medical spending account coupled with catastrophic benefits for very large expenses. This could significantly undermine the current. Defined-contribution health care benefits are a new way for employers to provide health care coverage to their employees, while no longer acting as brokers between employees and insurance companies contracted to provide benefits. An employer may choose from several different ways to put money into a health benefits account for each employee and offer the employee a menu of coverage options, with different funding levels and employee financial responsibility for each.

However, such plans have yet to assume a significant role in the insurance market, and few employers offer them as an alternative. The development of enhanced information technology and its use in hospitals, individual provider practices, and other segments of the health care delivery system are essential for improving the quality of care.

Better information technology can also support patients and family caregivers in crucial health decisions, strengthen both personal and population-based prevention efforts, and enhance participation in and coordination with public health activities.

See Chapter 3 for a discussion of the information technology needs of the governmental public health infrastructure. Crossing the Quality Chasm IOM, b formulated the case that information technology is critical to the redesign of the health care system to achieve a substantial improvement in the quality of care. A strong clinical information infrastructure is a prerequisite to reengineering processes of care; coordinating patient care across providers, plans, and settings and over time; supporting the operation of multidisciplinary teams and the application of clinical support tools; and facilitating the use of performance and outcome measures for quality improvement and accountability.

From the provider perspective, better information systems and more extensive use of information technology could dramatically improve care by offering ready access to complete and accurate patient data and to a variety of information resources and tools—clinical guidelines, decision-support systems, digital prescription-writing programs, and public health data and alerts, for example—that can enhance the quality of clinical decision making. Computer-based systems for the entry of physician orders have been found to have sizable benefits in enhancing patient safety Bates et al.

Despite profound growth in clinical knowledge and medical technology, the health care delivery system has been relatively untouched by the revolution in information technology that has transformed other sectors of society and the economy. Many health care settings lack basic computer systems to provide clinical information or support clinical decision making.

Even where electronic medical record systems are being implemented, most of those systems remain proprietary products of individual institutions and health plans that are based on standards of specific vendors.

The development and application of interoperable systems and secure information-sharing practices are essential to gain greater benefits from information technology. At present, only a few institutions have had the. Those efforts illustrate both the costs involved in developing health information systems and some of the benefits that might be expected.

So far, however, adoption of even common and less costly information technologies has been limited. Only a small fraction of physicians offer e-mail interaction 13 percent, in a poll , a simple and convenient tool for efficient communication with their patients Harris Interactive, Some of the documented reasons for the low level of physician—patient e-mail communication include concerns about lack of reimbursement for this type of service and concerns about confidentiality and liability.

These legitimate issues are slowly being addressed in policy and practice, but there is a long way to go if this form of communication is to achieve its potential for improving interactions between patients and providers. Enhanced information technology also promises to aid patients and the public in other ways. The Internet already offers a wealth of information and access to the most current evidence to help individuals maintain their own health and manage disease.

In addition, support groups and interactive programs offer additional approaches to empower consumers. Personalized systems for comprehensive home care may improve outcomes and reduce costs.

Other efforts to build a personal health record PHR created or cocreated and controlled by the individual—and instantly available to support treatment in any setting—suggest that the PHR may provide a comprehensive, accurate, and continuous record to support health and health care across the life span Jones et al.

A sophisticated health information infrastructure is also important to support public health monitoring and disease surveillance activities. Systems and protocols for linking health care providers and governmental public health agencies are vital for detecting emerging health threats and supporting appropriate decisions by all parties.

The committee cautions, however, that systems dedicated to a single use, such as bioterrorism, will not be optimal; systems designed to be comprehensive and flexible will be of greater overall value.

Ultimately, such systems should also allow the. For information technology to transform the health sector as it has banking and other forms of commerce that depend on the accurate, secure exchange of large amounts of information, action must be taken at the national level to develop the National Health Information Infrastructure NHII NRC, The committee endorses the call by the National Committee on Vital and Health Statistics NCVHS for the nation to build a twenty-first century health support system—a comprehensive, knowledge-based system capable of providing information to all who need it to make sound decisions about health.

Such a system can help realize the public interest related to quality improvement in health care and to disease prevention and health promotion for the population as a whole. The rapid development and widespread implementation of an extensive set of standards for technology and information exchange among providers, governmental public health agencies, and individuals are critical. To realize the full potential of the NHII, supportive changes in the social, economic, and legal infrastructures are also required.

Policies promoting the portability and continuity of personal health information are essential. Values, practices, relationships, laws, and investment and reimbursement policies must support the creation and use of data and information systems that are consistent with the vision for the NHII see Chapter 3 for an additional discussion and recommendation. The activities and interests of the health care delivery system and the governmental public health agencies clearly overlap in certain areas, but there is relatively little collaboration between them.

In addition, the authority of state health departments in quality monitoring, licensure, and rate setting can cause serious tensions between them and health care organizations.

The committee discusses the extent of this separation and the particular need for better collaboration, especially in regard to assuring access to health care services, disease surveillance activities, and partnerships toward broader health promotion efforts.

Within the public health system in the United States, collaboration between the health care sector and governmental public health agencies is. This reflects the divergence and separate development of two distinct sectors following the Second World War. As disciplines and professional fields, medicine and public health evolved with minimal levels of interaction, and often without recognition of the lost opportunities to improve the health of individuals and the population.

The health care and governmental public health sectors are also very unequal in terms of their resources, prestige, and influence on public policy. The failure to collaborate characterizes not only the interactions between governmental public health agencies and the organizations and individuals involved in the financing and delivery of health care in the private sector but also financing within the federal government.

Even the congressional authorizing committees for these activities are separate. For example, the Substance Abuse and Mental Health Services Administration, a PHS agency, administers block grants to states to augment funding for mental health and substance abuse programs, neither of which is well supported under Medicaid.

Until recently, the Medicaid waiver program, administered by CMS on behalf of the Secretary of Health and Human Services, did not provide protection of reimbursement rates for clinics within the safety-net system.

At the same time, the Health Resources and Services Administration, the PHS agency charged with funding federally qualified safety-net clinics for the poor, and the Indian Health Service were both seeking funds to support the increasing deficits of these clinics due to the growing number of uninsured individuals and the low rates of reimbursement for Medicaid clinics. The operational separation of public health and health care financing programs mirrors the cultural differences that characterize medicine and public health.

American fascination with technology, science, and medical interventions and a relatively poor understanding of the determinants of health see Chapter 2 or of the workings of the governmental public health agencies also contribute to the lower status, fewer resources, and limited influence of public health.

The committee views these status and resource differences as barriers to mutually respectful collaboration and to achieving the shared vision of healthy people in healthy communities. The committee also urges greater efforts on the part of the health care. Public health departments have always differed greatly in regard to the delivery of health care services, based on the availability of such services in the community and other reasons Moos and Miller, Some provide no personal health care services at all, whereas others provide some assortment of primary health care and safety-net services.

In general, however, there has been a decrease in the number of local governmental public health agencies involved in direct service provision. In a recent survey of public health agencies, primary care or direct medical care services were the least common services provided NACCHO, Despite this, 28 percent of local public health departments report that they are the sole safety-net providers in their communities Keane et al. During the s, Medicaid shifted from a fee-for-service program to a managed care model.

This change has been a challenge to the multiple roles of public health departments as community-based primary health care providers, safety-net providers, and providers of population-based or traditional public health services. The challenge has been both financial and organizational. First, managed care plans reimburse safety-net providers less generously than fee-for-service Medicaid providers do under Medicaid, federally qualified health centers benefited from a federal requirement for full-cost reimbursement , and they impose administrative and service restrictions that result in reduced overall rates of compensation IOM, a.

In many states and localities, these changes have decreased the revenue available to public health departments and public clinics and hospitals. In many cases, funds were no longer available for population-based essential public health services or had to be diverted to the more visibly urgent need of keeping clinics and hospitals open CDC, The result of this interplay is that many governmental public health agencies have found themselves in a strained relationship with managed care organizations: Second, the shift of Medicaid services to a managed care environment led some public health departments to scale down or dismantle their infrastructure for the delivery of direct medical care.

The recent trend of the exit of managed care from the Medicaid market has left some people without a medical home and, in cases of. This problem may be most acute in rural areas, where public health departments are often the sole safety-net providers Johnson and Morris, One strategy to help lessen the negative impacts of changes in health care financing undertaken by some public health departments has been the development of formal relationships e. Such arrangements have made possible some level of integration of health care and public health services, enhanced information exchange and continuity of care, and allowed public health departments to be reimbursed for the provision of some of the services that are covered by the benefits packages of managed care plans Martinez and Closter, At this time, governmental public health agencies are still called on to play a role in assurance broader than that which may be compatible with their other responsibilities to population health.

However, closer integration between these governmental public health agencies and the health care delivery system can help address the needs of the uninsured and underinsured. Denver Health, in Colorado, provides an intriguing example of a hybrid, integrated public—private health system Mays et al. Denver Health is the local county and city public health authority, as well as a managed care organization and hospital service.

Disease surveillance and reporting provide a classic exemplar of essential collaboration between the health care system and the governmental public health agencies. The latter rely on health care providers and laboratories to supply the data that are the basis for disease surveillance. For instance, in the fall of , reports from physicians who diagnosed the first cases of anthrax were essential in recognizing and responding to the bioterrorism attack.

States mandate the reporting of various infectious diseases e. Other types of public health surveillance activities,. Effective surveillance requires timely, accurate, and complete reports from health care providers. In the case of infectious diseases, if all systems work effectively, the necessary information regarding the diagnosis for a patient with a reportable disease is transmitted to the state or local public health department by a physician or laboratory.

For unusual or particularly serious conditions, public health officials offer guidance on treatment options and control measures and monitor the community for any additional reports of similar illness. For diseases like tuberculosis and sexually transmitted diseases, public health agencies facilitate active tracking and prophylactic treatment of persons exposed to an infected individual. Disease reporting requirements vary from state to state, although most states include diseases identified by the Centers for Disease Control and Prevention CDC as part of the National Notifiable Disease Reporting System.

Disease reporting is not complete, however. For diseases under national surveillance, from 6 to 90 percent of cases are reported, depending on the disease Teutsch and Churchill, ; Thacker and Stroup, Incomplete reporting may reflect a lack of understanding by some health care providers of the role of the governmental public health agencies in infectious disease monitoring and control.

In some instances, physicians and laboratories may be unaware of the requirement to report the occurrence of a notifiable disease or may underestimate the importance of such a requirement.

The difficulty of reporting in a busy practice is also a barrier. Notifiable disease reporting systems within public health departments with strong liaisons with the health care community are important in the detection and recognition of bioterrorism events. However, this valuable tool has not been well supported and, as noted earlier, suffers from issues of lack of timeliness and incomplete reporting, as well as complex or unclear reporting procedures and limited feedback from governmental public health agencies on how data are used Baxter et al.

Health care delivery systems may fear that the data will be used to measure performance, and concerns about patient confidentiality can also contribute to a reluctance to report some diagnoses.

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