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). Nearly 90 percent of employers' most popular plans cover well-baby care, whereas less than half cover contraceptive devices or drugs to prevent unwanted births. Legal, Regulatory, and Policy Interventions to Eliminate Racial and Ethnic Disparities in Health Care. As the committee observed in Chapter 1, American medicine and the basic and clinical research that inform its practice are generally acknowledged as the best in the world. Good primary care is associated with better birth weights (Politzer et al., 2001), lower smoking rates, less obesity, and higher rates of seat belt use (Shi et al., 1999) and is a major determinant of receiving preventive services such as blood pressure screening, clinical breast exams, and Pap smears (Bindman et al., 1996). Objective The WHO developed a manual outlining the preliminary organizational and health professionals' readiness to implement electronic medical records (EMR). Rice T, Pourat N, Levan R, Silbert LJ, Brown ER, Gabel J, Kim J, Hunt KA, Hurst KM. 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. Additionally, disabling chronic conditions affect all age groups, but about two-thirds are found in individuals over age 65. However, they are also enormously important for children. In general, however, there has been a decrease in the number of local governmental public health agencies involved in direct service provision. . Substantial increases in health insurance premiums are a clear indication of these economic stresses. 1996. 2002. Being uninsured, although not the only barrier to obtaining health care, is by all indications the most significant one. Health care delivery forms the most visible function of the health system, both to patients and the general public. False 2001. 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. The result of this interplay is that many governmental public health agencies have found themselves in a strained relationship with managed care organizations: on the one hand, encouraging their active partnership in an intersectoral public health system and, on the other, competing with them for revenues (Lumpkin et al., 1998). AAMC (Association of American Medical Colleges). Final Report, Networking Health: Prescriptions for the Internet, Children's Health under Medicaid: A National Review of Early Periodic Screening, Diagnosis and Treatment, Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community, Fiscal Year 2001 performance and accountability report, Driving the market to reduce medical errors through the Leapfrog California Patient Safety Initiative, Why Invest in Disease Prevention? Every country irrespective of its private, public or mixed health care system faces challenges with regard to quality, delivery and cost of services. The use of financial incentives and data-driven performance measurement strategies to improve physicians' delivery of services such as immunizations (IOM, 2002c) may account for the fact that managed care plans tend to offer the most comprehensive coverage of clinical preventive services and traditional indemnity plans tend to offer the least comprehensive coverage. 2002, Medicaid and Other State Healthcare Issues: The Current Situation, NASBO analysis: Medicaid to stress state budgets severely into fiscal 2003, Early release of selected estimates based on data from the JanuaryJune 2001 National Health Interview Survey, Information for Health: A Strategy for Building the National Health Information Infrastructure, Nurse Staffing and Patient Outcomes in Hospitals. Disease surveillance and reporting provide a classic exemplar of essential collaboration between the health care system and the governmental public health agencies. Integrated Delivery System. For example, traditional patterns of reporting may be lost as health care delivery shifts from inpatient to outpatient settings. Hospitals are also employers, and in the case of two Lawndale, Illinois, hospitals, collaboration with the local development corporation and other neighborhood organizations in 1999 made affordable local housing available to employees, helping to facilitate community development (University of Illinois, 1999). Delivery of high-quality care to chronically ill patients is especially challenging in a decentralized and fragmented system, characterized by small practices (AMA, 1998). 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. 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. Oral diseases are causally related to a range of significant health problems and chronic diseases, as well as individuals' ability to succeed in school, work, and the community (DHHS, 2000b). DEPARTMENT: Health Care EvaluationNORC's expertise and ongoing work in health care delivery and financing - including access to insurance, payment and delivery-system reform, benefit design, and quality measurement - advance stakeholders' understanding of policies and programs, facilitate implementation, and contribute to important improvements . Health care providers may also reduce their use of laboratory tests to confirm a diagnosis. 2002. Table 52 shows the distribution of sources of payment for treatment for mental health and addictive disorders in 1996. Americans now live longer. Although this committee was not constituted to investigate or make recommendations regarding the serious economic and structural problems confronting the health care system in the United States, it concluded that it must examine certain issues having serious implications for the public health system's effectiveness in promoting the nation's health. Cardiovascular disease and diabetes exemplify the problem. So far, however, adoption of even common and less costly information technologies has been limited. As the delivery of care becomes more complex across a wide range of settings, and the need to coordinate care among multiple providers becomes ever more important, developing well-functioning teams becomes a crucial objective throughout the health care system. 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. Managed care is undergoing rapid changes, some of which are likely to further undermine its viability. Vignettes drawn from the experience of American Hospital Association NOVA Award recipients illustrate the importance of investing in overall community health (AHA, 2002). coordination in healthcare is imperative. Nevertheless, as the NCVHS report describes, neither the opportunities nor the barriers to the development of the NHII are related solely to information technology. In the aggregate, these per capita expenditures account for 13.2 percent of the U.S. gross domestic product, about $1.3 trillion (Levit et al., 2002). 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. In addition, uninsured patients are making greater use of emergency departments for nonurgent care. Hence, more people can seek proper medication. 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. 2001. 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. Other efforts to build a personal health record (PHR) created or cocreated and controlled by the individualand instantly available to support treatment in any settingsuggest that the PHR may provide a comprehensive, accurate, and continuous record to support health and health care across the life span (Jones et al., 1999). 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). Employer acceptance may change in the face of double-digit insurance premium increases. In Providence, Rhode Island, a community partnership of nonprofit and independent hospitals and colleges works to improve children's quality of life by providing school-based health services, innovative and enhanced education through teacher and staff training, and support to improve home environments through housing advocacy (Health & Education Leadership for Providence, 2001; Providence Public School District, 2002). Subspecialty office care. As detailed in Crossing the Quality Chasm (IOM, 2001b: 27), effective health care for chronic disease management is a collaborative process, involving the definition of clinical problems in terms that both patients and providers understand; joint development of a care plan with goals, targets, and implementation strategies; provision of self-management training and support services; and active, sustained follow-up using visits, telephone calls, e-mail, and Web-based monitoring and decision support systems.. Avoid fragmentation of health plans along socioeconomic lines. In a further example, the Crozer-Keystone Health System that serves Chester, Pennsylvania, was declared a distressed municipality by the state in 1994. 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. The four basic components are financing, insurance, delivery, and payment. Taken together, these trends are beginning to place unparalleled strain on the health care safety net in many parts of the country. b the IOM Committee on the Consequences of Uninsurance (IOM, 2001a) found the following: 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. Strasz M, Allen DJ, Paterson Sandie AK. g In addition, the chapter discusses the responsibility of the health care system to recognize and play its appropriate role within the intersectoral public health system, particularly as it collaborates with the governmental public health agencies. Strengthen the stability of patientprovider relationships in publicly funded (more). 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. Bone mass measurements for people at risk of losing bone mass, Colorectal cancer screening (people age 50 and older), Diabetes services (coverage of self-management training and glucose monitoring supplies) for people with diabetes, Mammogram screening (women age 40 and older), Prostate cancer screening (men age 50 and older), Vaccinations (flu, pneumococcal pneumonia, hepatitis B), Outpatient nutrition counseling by registered dietitians for patients with diabetes and some types of kidney disease. 2000. Kaiser Family Foundation and 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. Hayward RA, Shapiro MF, Freeman HE, Corey CR. 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, 2000). Prevention and well care. Although some of this increase is to be expected because of the overall aging of the U.S. labor force, the proportion of workers who are age 35 and older is increasing more for RNs than for all other occupations (IOM, 1996). The demonstrations should be supported by adequate resources to enable innovative ideas to be fairly tested. Services, Consumers, Personnel, and Payment Hospitals vary in size, ownership, and types of services. For example, time pressures on physicians hamper their ability to accurately assess presenting symptoms, especially when cultural or language barriers are present. 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. Results from the William M. Mercer/Partnership for Prevention Survey of Employer Sponsored Plans, Prevention Priorities: Employers' Guide to the Highest Value Preventive Health Services, Transition Report to the New Administration: Strengthening Our Public Health Defense Against Environmental Threats, Barriers to care among racial/ethnic groups under managed care, Inequality in America: the contribution of health centers in reducing and eliminating disparities in access to care, Changes in insurance coverage and extent of care during the two years after first hospitalization for a psychotic disorder, Demand for health care information prompts mediainstitution alliances, The de facto US mental and addictive disorders service system. Second, they are the principal providers of specialized services and serve as regional referral centers for smaller towns or cities and rural areas. 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. 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. 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. By comparison, racial and ethnic minorities account for more than one-quarter of the nation's population. Schoenbaum M, Untzer J, Sherbourne C, Duan N, Rubinstein LV, Miranda J, Carney MF, Wells K. 2001. 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 facts about uninsurance in America are sobering (see Box 51). 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. tailored to your instructions. 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. Termination of Medi-Cal benefits: a follow-up study one year later, The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 19701998, Determinants of late stage diagnosis of breast and cervical cancer, The late-stage diagnosis of colorectal cancer: demographic and socioeconomic factors, Breast and cervix cancer screening among multiethnic women: role of age, health and source of care, Medicare costs in urban areas and the supply of primary care physicians, A profile of federally funded health centers serving a higher proportion of uninsured patients, Public Health Departments Adapt to Medicaid Managed Care, Local Public Health Practice: Trends & Models, Actual causes of death in the United States, Emergency department overcrowding in Massachusetts : making room in our hospitals, Health Insurance Coverage: Consumer Income, Time trends in late-stage diagnosis of cervical cancer: differences by race/ethnicity and income, Relationships between public and private providers of health care, The Global Burden of Disease. With such a system, a physician seeing an influx of patients with severe sore throats could use information on the current community prevalence of confirmed streptococcal pharyngitis and the antibiotic sensitivities of the cultured organisms to choose appropriate medications. Federal Supplementary Medical Insurance Trust Funds. The American Hospital Association (AHA, 2001a) reports that from 1994 to 1999, the number of emergency departments in the nation decreased by 8.1 percent (see Table 53). 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. CDC, National Center for Infectious Diseases Surveillance Resources, Program Information on Medicare Medicaid, SCHIP & Other Programs of the Centers for Medicare & Medicaid Services, Medicare program information, Section III.B.1, State Children's Health Insurance Program: Fiscal year 2001 annual enrollment report, National Estimates of Expenditures for Substance Abuse Treatment, 1997, Health-care costs jump at CalPERS: big premium increase may signal trend, Mental health service utilization by African Americans and whites: The Baltimore Epidemiologic Catchment Area Follow-up, Clinical Guidelines for Major Depressive Disorder, Frequent overcrowding in U.S. emergency departments, Mental Health: A Report of the Surgeon General, Objective 18: mental health and mental disorders, Oral Health in America: A Report of the Surgeon General, 2002 CMS Statistics. 2002. The U.S. health care system is complex, and it is difficult to reduce all of its elements, influences, and decision makers into a simple diagram.

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