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. g 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. For convenience, however, the committee uses the common terminology of health care delivery system. The component of running the system allows for quality control, making new . . 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. Access to care: how much difference does Medicaid make? According to the American Hospital Association (2001a), the demand for emergency department care increased by 15 percent between 1990 and 1999. 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. Many forms of publicly or privately purchased health insurance provide limited coverage, and sometimes no coverage, for these services. The National Community Care Network Demonstration Program, sponsored by the Hospital Research and Education Trust (HRET), reports on hospitals across the country that are supporting activities beyond the delivery of medical care to improve health status and quality of life in local communities. This chapter addresses the issues of access, managing chronic disease, neglected health care services (i.e., clinical preventive services, oral, and mental health care and substance abuse services), and the capacity of the health care delivery system to better serve the population in terms of cultural competence, quality, the workforce, financing, information technology, and emergency preparedness. Aiken L, Clarke S, Sloane D, Sochalski J, Busse R, Clarke H, Giovannetti P, Hunt J, Rafferty A, Shamian J. 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. 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. Needleman J, Buerhaus PI, Mattke S, Stewart M, Zelevinsky K. 2001. 2002. With revenues increasing by only about 5 percent in the same period, Medicaid now accounts for more than 20 percent of total state spending (NASBO, 2002b). Programs included attracting other businesses to Chester, setting up a business incubator building, and colocating multiple health and social programs to facilitate one-stop shopping. The effort has had a major stabilizing effect on Chester, and although overall health indicators are still behind state averages for chronic diseases, they are improving. DoD's dual health care mission is carried out through a direct care system that comprises 530 Army, Navy, and Air Force Military Treatment Facilities (MTFs) worldwide. . Implement patient education programs to increase patients' knowledge of how to best access care and participate in treatment decisions. These included. To realize the full potential of the NHII, supportive changes in the social, economic, and legal infrastructures are also required. This may reflect the limited range of benefits covered by Medicare, as well as other barriers such as copayments, participants' unfamiliarity with the services, or the failure of physicians to recommend them. Even when insured, limitations on coverage may still impede people's access to care. These circumstances force public health departments to provide personal health care services instead of using their resources and population-level approaches to guide and support community efforts to change the conditions for health. 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. This chapter has outlined the main areas in which the health care delivery system and the governmental public health agencies interface. The challenge has been both financial and organizational. Department of Defense (2002). Bindman and colleagues (1995) similarly concluded that at the community level, there is a strong positive association between health care access and preventable hospitalization rates, suggesting that these rates can serve as an indication of access to care. It would be a costly mistake to create additional emergency and inpatient capacity before decompressing demand by improving access to primary care services. 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. 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 1990s, 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. Partnership for Prevention Survey of Employer Support for Preventive Services. Mental health parity: what are the gaps in coverage? Findings from Coverage Matters. Patients regularly spent significant portions of their admission on gurneys in a hallway. Provide greater resources to the Department of Health and Human Services Office of Civil Rights to enforce civil rights laws. Trude S, Christianson JB, Lesser CS, Watts C, Benoit AM. It has also reduced the time that physicians spend with patients and the quality of the clinical encounter. A recent national hospital survey (AHA, 2001b) found that of 168,000 vacant positions, 126,000 were for RN positions. Private insurance is predominantly purchased through employment-based groups and to a lesser extent through individual policies (Mills, 2002). "The RHRP helps to ensure that all service members . 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. Each element is equally important in providing high-quality care to our patients in the 11 countries where . 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. Health care delivery systems differ depend- ing on the arrangement of these components. 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). Health care expenditures and mortality experience, Trends in health insurance coverage: a look at early 2001 data, Oral health: dental disease is a chronic problem among low-income populations, Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health Screening Services, Strategic objective: the health needs of an aging and diverse population, The causes of vulnerability: disentangling the effects of race, socioeconomic status and insurance coverage on health, Comparison of uninsured and privately insured hospital patients: condition on admission, resource use, and outcome. the IOM Committee on the Consequences of Uninsurance (IOM, 2001a) found the following: Forty-two million people in the United States lacked health insurance coverage in 1999 (Mills, 2000). org/about/community/services/, www.nasbo.org/Publications/PDFs/medicaid2003. DHHS (Department of Health and Human Services). Collect and report data on health care access and utilization by patients' race, ethnicity, socioeconomic status, and, where possible, primary language. Policies promoting the portability and continuity of personal health information are essential. 1999. 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. 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. Diagnoses of interest are grouped into syndromes, and rates of new episodes are computed for all of eastern Massachusetts and each census tract. Bates D, Cohen M, Leape LL, Overhage JM, Shabot MM, Seridan T. 2001. To deliver the type of health care envisioned in Crossing the Quality Chasm (IOM, 2001b), 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. In addition, segmentation of health care plans was found to play a significant role in producing poorer care for racial and ethnic minorities because they are more likely than whites to be enrolled in lower-end health plans (IOM, 2002b). What are the two main objectives of a healthcare delivery system? Channeling purchasing power into community business, Housing development through capital leverage, Minority Graduates of US Medical Schools: Trends, 19501998, Emergency departmentsan essential access point to care, The health care workforce shortage and its implication for America's hospitals, Depression in Primary Care: Treatment of Major Depression, Nurses' report on hospital care in five countries, Lower Medicare mortality among a set of hospitals known for good nursing care, Dental insurance is essential, but not enough, Socioeconomic characteristics of medical practice 1997/ 98, Emergency departments and crowding in United States teaching hospitals, Unmet health needs of uninsured adults in the United States, Journal of the American Medical Association, Health insurance and access to care for symptomatic conditions, Beyond the Medical Model: Hospitals Improve Community Building, Community Care Network (CCN) Briefings, Fall 2001, Reducing the frequency of errors in medicine using information technology, Journal of the American Medical Informatics Association, Effect of computerized physician order entry and a team intervention on prevention of serious medication errors, The status of local health care safety-nets, Assessing Core Capacity for Infectious Diseases Surveillance, Final Report prepared for the Office of the Assistant Secretary for Planning and Evaluation. For Americans to enjoy optimal healthas individuals and as a populationthey must have the benefit of high-quality health care services that are effectively coordinated within a strong public health system. Four Components of a Health Care Delivery System Healthcare delivery systems can be divided into 4 major components or functions: Services: Health care assistance available.. 1999. 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, 1997). However, they are also enormously important for children. 1998. Washington (DC): National Academies Press (US); 2002. Prevention and well care. The Surgeon General's report on mental illness (DHHS, 1999) estimates that more than one in five adults are affected by mental disorders in any given year (see Box 56) and 5.4 percent of all adults have a serious mental illness. 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, 2002). Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. Seedco and the Non-Profit Assistance Corporation (N-PAC). The funding prioritizes research projects that focus on the delivery of military health care and system-level innovations that impact cost and outcomes. The U.S. Preventive Services Task Force calls these interventions vitally important.. The number of eligible children fell by more than half a million between 1995 and 1996. Other changes in the health care delivery system also raise concerns about the infectious disease surveillance system. Consumer demands for more choice and greater flexibility are weakening restrictions on access to providers and limitations on services. 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). The adequacy of hospital capacity cannot be assessed without considering the system inefficiencies that characterize current insurance and care delivery arrangements. (Additional discussion of these and other neglected forms of care appears later in this chapter.). The ability of academic medicine to evolve into a broader mission will depend on changes in payment systems that may be difficult to achieve and on internal changes within AHCs that may be equally difficult. Sturm R, Jackson CA, Meredith LS, Yip W, Manning WG, Rogers WH, Wells KB. People turn to safety-net providers for a variety of reasons: some because they lack health insurance and others because there are no other providers in the area where they live or because language and cultural differences make them uncomfortable with mainstream care. The forecast for major oral health problems among the nation's fastest-growing population group, Hispanics, is especially alarming. Increasing their numbers and assuring their viability can, to some degree, improve the availability of care. Within the Department of Health and Human Services (DHHS), the Centers for Medicare and Medicaid Services (CMS) administer the two public insurance programs with little interaction or joint planning with agencies of the U.S. Public Health Service (PHS). Additionally, public funding supports directly delivered health care (through community health centers and other health centers qualified for Medicaid reimbursement) accessed by 11 percent of the nation's uninsured, who constitute 41 percent of patients at such health centers (Markus et al., 2002). 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., 1999). 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.g., panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and phobia). The health care sector in the United States consists of an array of clinicians, hospitals and other health care facilities, insurance plans, and purchasers of health care services, all operating in various configurations of groups, networks, and independent practices. Components of Healthcare Delivery. Facts About Mental Illness. 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. The emergency departments of hospitals in many areas of New York City routinely operated at 100 percent capacity (Brewster et al., 2001). 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. 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. The committee endorses the call by the National Committee on Vital and Health Statistics (NCVHS) (2002) for the nation to build a twenty-first century health support systema comprehensive, knowledge-based system capable of providing information to all who need it to make sound decisions about health. Substance Abuse and Mental Health Services Administration. 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. For children, too, being uninsured tends to reduce access to health care and is associated with poorer health. However, the basic functional components include running the system, the different branches of the system, how services are rendered, how the services are funded, and manufacturing of new products (Barton, 2010, p. 6-8). Safety-net service providers, which include local and state governmental agencies, contribute to the public health system in multiple ways. For most Americans, having health insurance under a private plan or through a publicly financed programis a threshold requirement for routine access to health care. 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. Is managed care leading to consolidation in healthcare markets? Data for children are less reliable, but the overall prevalence of mental disorders is also estimated to be about 20 percent (DHHS, 1999). 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. IOM. 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 Emerging Infections Program (EIP) is a collaboration among CDC, state public health departments, and other public health partners for the purpose of conducting population-based surveillance and research on infectious diseases. 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. Counseling to address serious health riskstobacco use, physical inactivity, risky drinking, poor nutritionis least likely to be covered by an employer-sponsored (more). The IOM Committee on the Consequences of Uninsurance found that [u]ninsured adults receive health services that are less adequate and appropriate than those received by patients who have either public or private health insurance, and they have poorer clinical outcomes and poorer overall health than do adults with private health insurance (IOM, 2002a: 87). h Over the same period, medical and surgical bed capacities were reduced by 17.7 percent, ICU bed capacities were reduced by 2.8 percent, and specialty bed (including burn bed) capacities were reduced by 3.4 percent. Exploring external revenue streams and advocating for changes in current health care financing and funding for such efforts (VHA Health Foundation and HRET, 2000). 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. 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. 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. of those objectives, a healthcare delivery system concept model was developed (see Figure 3) that is comprised of three major components: primary . Solis JM, Marks G, Garcia M, Shelton D. 1990. Lumpkin JR, Landrum LB, Oldfield A, Kimel P, Jones MC, Moody CM, and Turnock BJ. Health Research and Educational Trust (HRET). White paper, Emergency department overcrowding: an action plan, Improving chronic illness care: translating evidence into action, Health care utilization among Hispanics: findings from the 1994 Minority Health Survey, Recent care of common mental disorders in the United States, Geographic variation in expenditures for physician' services in the United States, Stage at diagnosis in breast cancer: race and socioeconomic factors, Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial, Free care: a quantitative analysis of health and cost effects of a national health program for the United States, Routine outcome monitoring in a public mental health system: the impact of patients who leave care, The quality of care for depressive and anxiety disorders in the United States, Use of cancer screening practices by Hispanic women: analyses by subgroup. Contrary to popular belief, recent immigrants accounted for a relatively small proportion of the uninsured (less than one in five). The complexity of the health system continues to grow and can be characterized by more to know, do, manage, and watch for more people than at any point in history. Figure 1-1 illustrates that a health care delivery system incorporates four functional componentsfinancing, insurance, delivery, and payment, or the quad-function model. . 1999. Leigh WA, Lillie-Blanton M, Martinez RM, Collins KS. The current health care system does not meet the challenge of providing clinically appropriate and cost-effective care for the chronically ill. NACCHO (National Association of County and City Health Officials). The advent of managed care plans that seek services from the lowest-cost appropriate provider and changes in federal (Medicare) reimbursement policies that reduced subsidies for costs associated with AHCs' missions in education, research, and patient care have created considerable pressure on academic institutions to increase efficiency and control costs.