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., 1998). SOURCE: Brewster et al. Our Model | Kaiser Permanente Those without health insurance or without insurance for particular types of services face serious, sometimes insurmountable barriers to necessary and appropriate care. Denver Health is the local (county and city) public health authority, as well as a managed care organization and hospital service. 1995. Kaiser Permanente, for example, is investing $2 billion in a web-based system encompassing all of the critical features needed to provide patient-centered, high-quality care: a nationwide clinical information system, a means for patients to communicate with doctors and nurses to seek medical advice, access by clinicians to clinical guidelines and other knowledge resources, and computerized order entry (Krall, 1998). 1986. True Which type of hospital earns a profit from the services that are provided? Legal, Regulatory, and Policy Interventions to Eliminate Racial and Ethnic Disparities in Health Care. Payment & Delivery Models | Care Delivery Models | AMA Coverage Matters, The issues are complex, and the failures of health care reform efforts over the past 30 years testify to the difficulty of crafting a solution. 2002. To support the system, the United States spends more per capita on health care than any other country ($4,637 in 2000) (Reinhardt et al., 2002). Governmental public health agencies also depend on astute clinicians to inform them of sentinel cases of recognized diseases that represent a special threat to the public's health and of unusual cases, sometimes without a confirmed diagnosis, that may represent a newly emerging infection, such as Legionnaires' disease or West Nile virus in North America. Delivery. Mandelblatt JS, Gold K, O'Malley AS, Taylor K, Cagney K, Hopkins JS, Kerner J. In its report Many hospitals and health care systems have seen the value of going beyond the needs of the individuals who enter the health care system to engage in broader community health action, even within the constraints of the current environment. Insurance plans and providers scramble to adapt and survive in a rapidly evolving and highly competitive market; and the variations among health insurance planswhether public or privatein eligibility, benefits, cost sharing, plan restrictions, reimbursement policies, and other attributes create confusion, inequity, and excessive administrative burdens for both providers of care and consumers. 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, 2001) (see Box 53). A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020, Local Public Health Agency Infrastructure: A Chartbook, Medicaid and Other Health Care Issues. 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., 2001). Of the 22.9 million children eligible for the EPSDT program in 1996, only 37 percent received a medical screen through the EPSDT program. Henry J. Kaiser Family Foundation and The Organization and Delivery of Health Services (ODHS) study section reviews applications focused on the organization and delivery of health services from a systems level, including health care financing, insurance, access, utilization and the provision of health services at the population level. Heffler S, Smith S, Won G, Clemens MK, Keehan S, Zezza M. 2002. Nevertheless, as the NCVHS report describes, neither the opportunities nor the barriers to the development of the NHII are related solely to information technology. 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. To outline the four key functional components of a health care de-livery system To discuss the primary characteristics of the US health care system from a free market perspective To emphasize why it is important for health care managers to under-stand the intricacies of the health care delivery system To get an overview of the . The operational separation of public health and health care financing programs mirrors the cultural differences that characterize medicine and public health. The patient-centered medical home (PCMH) model is one such model that aims to deliver coordinated, accessible healthcare to improve outcomes and decrease costs. Other types of public health surveillance activities, such as registries for cancer cases and for childhood immunizations, also depend on reporting from the health care system. The growing cost of health care has obvious implications for the nation's readiness to address the problems discussed in this chapter. Ready access to necessary clinical expertise. Findings from Coverage Matters. 1998. 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, 2000). 2002. What makes up the healthcare system? 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. However, less than a third of women in the study setting had at least four contacts, with the first occurring in the first trimester. 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). 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., 1993; Kessler et al., 1994). Health care delivery - World Health Organization 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. Academic health centers (AHCs) serve as a critical interface with governmental public health agencies in several ways. Kaiser Family Foundation and Wagner and colleagues (1996) 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. Only a small fraction of physicians offer e-mail interaction (13 percent, in a 2001 poll), a simple and convenient tool for efficient communication with their patients (Harris Interactive, 2001). Two particular quality problems have special significance in terms of assuring the health of the population: disparities in the quality of care provided to racial and ethnic minorities and inadequate management of chronic diseases. Young children were significantly more likely to be screened: 76 percent of infants under age 1 were screened in 1996, whereas 18 percent of adolescents ages 15 to 20 were screened in 1996. 1999. Data Scientist - Healthcare Claims Analytics - Remote or Hybrid Office 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., 2000). Components of the U.S. health care system. Looking at 12 communities, Brewster and colleagues (2001) found that on average in 2001, 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. 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, 2001c). Scientific and technological advances will permit clinical care to intervene early in a disease process by identifying and modifying personal risk. This oversight is often reflected by health insurance coverage restrictions that exclude oral (more). Nurse Staffing in Hospitals and Nursing Homes: Is It Adequate? It is also associated with having a regular source of care and with greater and more appropriate use of health services. Furthermore, poor-quality health care is an important independent variable contributing to lower health status for minorities (IOM, 2002b). However, the focus on these two health care professional shortage areas does not suggest the absence of problems in other fields. Mexican-American adults and children are more likely to have untreated decayed teeth than any other population group. 2002. 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. Chronic conditions, defined as illnesses that last longer than 3 months and that are not self-limiting, affect nearly half of the U.S. population. Findings from the National Sample Survey of Registered Nurses, Public health reporting flaws spell trouble: doctors complain about requirements that appear to lack follow-through, Primary Care: Balancing Health Needs, Services and Technology, The role of primary care in improving population health and equity in the distribution of health: an unappreciated phenomenon, Policy-relevant determinants of health: an international perspective, EPSDT: Early Periodic Screening Detection and Treatment: a snapshot of service utilization, Health insurance may be improvingbut not for individuals with mental illness, Mental health care utilization in prepaid and fee-for-service plans among depressed patients in the medical outcomes study, SAMHSA fact sheet: analysis of alcohol and drug abuse expenditures in 1997, Principles and Practices of Public Health Surveillance, Future directions for comprehensive public health surveillance and health information systems in the United States, Employer-sponsored health insurance: pressing problems, incremental changes, Linking affordable housing to community development, Building Higher Education Community Development Corporation Partnerships, National Preparedness: Ambulance Diversions Impede Access to Emergency Rooms, Budget of the United States Government. Coverage Matters, NCVHS (National Committee on Vital and Health Statistics). 2001. Coalition members decided to tackle, in order, injuries caused by car accidents, violence, falls, and burns, through 11 initiatives involving more than 80 community organizations and agencies. In this system, health care is provided and financed by the government through tax payments, just like the police force or the public library. Even the congressional authorizing committees for these activities are separate. The fact that more than 41 million peoplemore than 80 percent of whom are members of working familiesare uninsured is the strongest possible indictment of the nation's health care delivery system. Nearly half of those with a chronic illness have more than one such condition (IOM, 2001a). SOURCE: Adapted from Olson et al. Lasker and colleagues observed, [t]he dominant, highly respected medical sector focused on individual patients, emphasizing technologically sophisticated diagnosis and treatment and biological mechanisms of disease. It includes pharmaceuticals, biotechnology and diagnostic laboratories. org/about/community/services/, www.nasbo.org/Publications/PDFs/medicaid2003. Computer-based systems for the entry of physician orders have been found to have sizable benefits in enhancing patient safety (Bates et al., 1998, 2001; Schiff et al., 2000). 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. Subspecialty office care. Although these various individuals and organizations are generally referred to collectively as "the health care delivery system," the phrase suggests an order, integration, and accountability that do not exist. 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. More than 90 percent of systemic diseases have oral manifestations. This committee was not constituted to make specific recommendations about health insurance. Hence, more people can seek proper medication. 1996. These factors, in turn, improve the likelihood of disease screening and early detection, the management of chronic illness, and the effective treatment of acute conditions, IOM notes in a recent report (IOM, 2002a: 6). To ensure healthy patients, you must have healthy health care systems. Late-stage diagnosis of breast cancer in women of lower socioeconomic status: public health implications, Primary care physicians and specialists as personal physicians. The fourth component is health care. Leigh WA, Lillie-Blanton M, Martinez RM, Collins KS. As a result of the nation's increased awareness of bioterrorist threats, there are concerns about the implications of copayments and other financial barriers to health care. The experiments should effectively link delivery systems with other components of the public health system and focus on improving population health while eliminating disparities. Nearly 3 out of every 10 Americans, more than 70 million people, lacked health insurance for at least a month over a 36-month period. Taken in the aggregate, these funding streams are neither adequate nor reliable enough to meet the needs of individuals with serious mental disorders (IOM, 2000a). Furthermore, non-academic community health centers also frequently have close ties to their communities, collaborating to assess local health needs, providing needed services, and supporting community efforts with research expertise and technical assistance in planning and evaluation. Health Care Delivery System - an overview - ScienceDirect The four function- al components make up the quad-function model. (Eds.). Partnership for Prevention Survey of Employer Support for Preventive Services. This rule reduced the cost of health insurance coverage. Some provide no personal health care services at all, whereas others provide some assortment of primary health care and safety-net services. Smith V, Ellis E, Gifford K, Ramesh R, Wachino V. 2002. However, such plans have yet to assume a significant role in the insurance market, and few employers offer them as an alternative. The health care sector also includes regulators, some voluntary and others governmental. . 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. The term "health care organization" is meant to encompass all settings of care in which the diagnostic process occurs, such as integrated care delivery settings, hospitals, clinician practices, retail . Concerted efforts should be directed to improving this nation's capacity and ability to monitor the changing structure, capacity, and financial stability of the safety net to meet the health care needs of the uninsured and other vulnerable populations. For example, in 1994, Parkland Health and Hospital System in Dallas noted that injury rates in the community were three times the national average and that trauma admissions had jumped 38 percent in one year (53 percent of that care is uncompensated). 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, 2002b). These benefits are most easily achieved under a fully capitated, group practice model: patients enroll with a health care organization that is paid a certain amount per member per month to provide all necessary or indicated services to the enrolled population, and physicians are paid a monthly fee or are salaried, which separates payment from the provision of individual services. If the goals of population health are to be realized, the focus must extend beyond the traditional clinical setting to . Between 1991 and 1996, the number of children eligible for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program increased by roughly 5.7 million, with (more). Needleman J, Buerhaus PI, Mattke S, Stewart M, Zelevinsky K. 2001. Furthermore, public health students and preventive medicine residents gain practical experience in health department rotations, where they participate in program planning and evaluation and learn about assessing a community's health care needs and implementing strategies that change the conditions for 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. f Three Principles for Improving Health Care Delivery 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. Schiff GD, Aggarwal HC, Kumad S, McNutt RA. Access to care is constrained by limitations on insurance coverage that are greater than those imposed for other diseases. When people think about the components of good health, they often forget about the importance of good oral health. g Reports of sentinel events have proved useful for the monitoring of many diseases, but such reports may be serendipitous and generated because of close clustering, unusual morbidity and mortality, novel clinical features, or the chance availability of medical expertise. 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. What are the four functions of health systems? (Eds.). 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. The type of health plan is the most important predictor of coverage (RWJF, 2001). The evidence that insurance makes a difference in health outcomes is well documented for preventive, screening, and chronic disease care (IOM, 2002b). The funding prioritizes research projects that focus on the delivery of military health care and system-level innovations that impact cost and outcomes. Focuses on quality of care, not volume of services provided Aligns incentives across all parts of our system, with patients at the center, delivering high-value care and keeping costs reasonable Invests in new technologies and innovations to advance quality of care 1991. coordination in healthcare is imperative. The shortage of hospital-based nurses reflects several factors, including the aging of the population, declining nursing school enrollment numbers (Sherer, 2001), the aging of the nursing workforce (the average age increased from 43.1 years in 1992 to 45.2 years in 2000) (Spratley et al., 2000), and dissatisfaction among nurses with the hospital work environment. In a study analyzing more than 5 million patient discharges from 799 hospitals in 11 states, Needleman and colleagues (2001) consistently found that higher RN staffing levels were associated with a 3 to 12 percent reduction in indicatorsincluding lower rates of urinary tract infections, pneumonia, shock, and upper gastrointestinal bleeding and shorter lengths of staythat reflect better inpatient care. Although Billings and colleagues focused on the preventable demands for hospital care among low-income and uninsured populations, Closing the Quality Chasm (IOM, 2001b) makes clear that the misuse of services also characterizes disease management among insured chronically ill patients. Such plans are characterized by higher per capita resource constraints and stricter limits on covered services (Phillips et al., 2000). Quality health care can be defined in many ways but there is growing acknowledgement that quality health services should be: Effective - providing evidence-based healthcare services to those who need them; Safe - avoiding harm to people for whom the care is intended; and Underlying all of these problems is the absence of a national health information infrastructure to support research, clinical medicine, and population-level health. Among physicians, about 3 percent are African American, 2.2 percent are Hispanic, and 3.6 percent are Asian (AAMC, 2000). Predicting the next configuration of insurance and plan delivery systems is dangerous in a system undergoing such rapid transition. Personalized systems for comprehensive home care may improve outcomes and reduce costs. e However, the increase in health spending also reflects the success of federal and state efforts to enroll more low-income children in Medicaid and the State Children's Health Insurance Program, increased enrollment in Medicare as the population ages, and some erosion of unpopular cost-control features imposed by managed care plans. 1. In order to understand the issues currently facing the contemporary mental health care delivery system, it is useful to trace its evolution. Strengthen the stability of patientprovider relationships in publicly funded health plans. A CDC-funded project of the Massachusetts Department of Public Health and the Harvard Vanguard Medical Associates (a large multi-specialty group) offers a glimpse of the benefits to be gained through collaboration between health care delivery systems and governmental public health agencies and specifically through the effective use of medical information systems (Lazarus et al., 2002). Crowding in hospital emergency departments has been recognized as a nationwide problem for more than a decade (Andrulis et al., 1991; Brewster et al., 2001; McManus, 2001; Viccellio, 2001).