Most recipients (87 percent) of specialty treatment for alcohol or drug abuse receive it in outpatient settings (RWJF, 2001), but overall, less than one-fourth of those who need treatment get it. But how is organized in different countries? (Additional discussion of these and other neglected forms of care appears later in this chapter.). Boards of Trustees, Federal Hospital Insurance and Community Health Improvement Strategy. Data for children are less reliable, but the overall prevalence of mental disorders is also estimated to be about 20 percent (DHHS, 1999). At the same time, advances in information technology and the explosion of knowledge from biomedical research have enormous implications for the role of AHCs in the health care system and in population health. Given its potential to reach such a high proportion of the nation's neediest children, the program could have a very positive, widespread impact on children's health. Oral Health as a Component of Total Health. Trude S, Christianson JB, Lesser CS, Watts C, Benoit AM. The unique characteristic of primary care is the role it plays as a regular or usual source of care for patients and their families. c 2000. In its report What makes up the healthcare system? Loosely affiliated physician networks have no ability to identify their populations and develop programs specifically based on the epidemiology of the defined group. 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. 1997. 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. Ensure that services are cost- effective and meet established standards of quality. The committee focused on the problem of insurance and access to care. 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. Components of Healthcare Delivery. Health care's structure and incentives are technology and procedure driven and do not support time for the inquiry and reflection, communication, and external relationship building typically needed for effective disease prevention and health promotion. SOURCE: Brewster et al. The health care sector also includes regulators, some voluntary and others governmental. 2000. 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. 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. (IOM, 2000a: 206). "The RHRP helps to ensure that all service members . 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. Although these steps can be expected to improve the nation's health and may even reduce costs over time, the initial investment will be substantial. On the other hand, the readiness assessment in Ethiopia only includes the evaluation of health professionals, leaving out organisational readiness 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). 2002. Public sources provide more than two-thirds of the funding for alcohol and drug treatment facilities. 1. Epidemiologic Catchment area prospective 1-year prevalence rates of disorders and services, Cross-national comparisons of health systems using OECD data, 1999, The economic burden of schizophrenia: conceptual and methodological issues, and cost estimates, Handbook of Mental Health Economics and Health Policy: Schizophrenia, Trends in job-based health insurance coverage, Substance Abuse: The Nation's Number One Health Problem. Crossing the Quality Chasm (IOM, 2001b) 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. 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. In a recent survey of public health agencies, primary care or direct medical care services were the least common services provided (NACCHO, 2001). 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. The value of this type of real-time monitoring of unusual disease outbreaks is obvious for early identification of bioterrorism attacks as well as for improvements in clinical care and population health. The facts about uninsurance in America are sobering (see Box 51). The U.S. Preventive Services Task Force calls these interventions vitally important.. This increase comes from the growth of the older population and the proportion of the overall population with chronic conditions, along with the introduction of new and more expensive drugs, many of which are used to treat chronic conditions. Schulberg H, Katon W, Simon G, Rush AJ. GAO (2001b). It is unclear how the types of delivery systems in which PCMHs operate differentially impact outcomes. The difficulty of reporting in a busy practice is also a barrier. Under the guidance of an external review panel, HRET and the Voluntary Hospital Association of America (VHA) Health Foundation reviewed the experiences of recipients of the Foster G. McGaw Prize3 from 1986 to 1998 and VHA Community Health Improvement Leadership Awards from 1996 to 1998. 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). HELP (Health & Education Leadership for Providence). 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 . Leigh WA, Lillie-Blanton M, Martinez RM, Collins KS. 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, 2002b) and aimed at eliminating racial and ethnic disparities in health care (see Box 58). By comparison, racial and ethnic minorities account for more than one-quarter of the nation's population. 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. 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. 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. In fact, as Healthline's Nina Lincoff explains, about 20 percent of physicians now offer concierge services or intend to do so in the near future. The existing health-care delivery system in the United States is a conglomerate of health practitioners, agencies, and organizations, all of which share the mission of health-care delivery but operate more or less independently. Many forms of publicly or privately purchased health insurance provide limited coverage, and sometimes no coverage, for these services. As seen in Figure 1, there are four standard components of healthcare information systems: operational, financial, administrative, and patient information. Schiff GD, Aggarwal HC, Kumad S, McNutt RA. Poor Mexican-American children ages 2 to 9 have the highest proportion of untreated decayed teeth (70.5 percent), followed by poor non-Hispanic African-American children (67.4 percent). Policies promoting the portability and continuity of personal health information are essential. 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. Although at the time the health system had been increasing its health care outreach programs, it realized it had to look at root causes. As the largest employer in Chester, the system organized Community Connections, a mosaic of health, economic, and social programs and services developed in partnership with 20 other organizations, a local university, and governmental agencies. 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. CDC (Centers for Disease Control and Prevention). 1994. 1999. Untreated ear infections, for example, can have permanent consequences of hearing loss or deafness. One of the most striking aspects of Covid-19 is that it often exploits underlying chronic conditions such as diabetes, heart disease, and obesity. However, there are examples of wide-reaching businesshealth care linkages, such as the efforts to ensure quality of care and enhanced consumer choice undertaken by the Pacific Business Group on Health (see Chapter 6). For example, time pressures on physicians hamper their ability to accurately assess presenting symptoms, especially when cultural or language barriers are present. From a public health perspective, such a system would permit continuous analysis of data from a number of clinical sites, enabling rapid recognition and response to new disease patterns in the community (see Chapter 3 for a discussion of syndrome surveillance). During the 1990s, the spread of managed care practices contributed to reductions in overall hospital admissions, in the length of hospital stays, and in emergency department visits. What are the two main objectives of a healthcare delivery system? Payment & Delivery Models. States are largely . 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. DHHS (2002). 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. 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. These trends do not appear to be a temporary, cyclical phenomenon. Funding to support the public mental health system comes from reimbursements for services provided to Medicare and Medicaid participants, from federal block grants to states, and from state and local funds that support community-based programs and hospital care. The fourth component is health care. 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). This chapter focuses on the actions that health care organizations can take to design a work system that supports the diagnostic process and reduces diagnostic errors (see Figure 6-1). Being uninsured, although not the only barrier to obtaining health care, is by all indications the most significant one. According to the Department of Health and Human Services (DHHS) Office of Health Promotion and Disease Prevention, more than 150 million Americans have limited or no dental insurance, nearly four times the number who lack insurance for medical care (cited by Allukian, 1999). With the projected growth in the number of people over age 65 increasing from 13 percent of the population to 20 percent, the need for care for chronic conditions will also continue to grow. 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. Uninsured persons with traumatic injuries were less likely to be admitted to the hospital, received fewer services when admitted, and were more likely to die than insured trauma victims (Hadley et al., 1991). Underlying all of these problems is the absence of a national health information infrastructure to support research, clinical medicine, and population-level health. Welch WP, Miller ME, Welch HG, Fisher ES, Wennberg JE. AAMC (Association of American Medical Colleges). Because insurance status affects access to secure and continuous care, it also affects health, leading to an estimated 18,000 premature deaths annually (IOM, 2002a). In addition, uninsured patients are making greater use of emergency departments for nonurgent care. Bates D, Cohen M, Leape LL, Overhage JM, Shabot MM, Seridan T. 2001. What are the primary objectives of a health care delivery system? Key Indicators for Policy, Early and periodic screening, diagnosis and treatment and managed care, Prescribing potassium despite hyperkalemia: medication errors uncovered by linking laboratory and pharmacy information systems, Uninsured and unstably insured: the importance of continuous insurance coverage, Cost-effectiveness of practice-initiated quality improvement for depression, Best clinical practice: guidelines for managing major depression in primary care, Case studies: Montefiore Medical Center Loan, Income inequality, primary care, and health indicators, Medicaid spending growth: results from a 2002 Survey, The direct and indirect effects of cost-sharing on the use of preventive services, Acculturation, access to care, and use of preventive services by Hispanics: findings from NHANES, 19821984, The Registered Nurse Population. However, they are also enormously important for children. Introduction Health care delivery system is a network of integrated components designed to work together coherently,to provide healthcare to a population in various settings. Embedded in these demographic changes is a dramatic increase in the prevalence of chronic conditions. Teutsch SM, editor; , Churchill RE, editor. 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. With start-up funding from a local foundation, its own fundraising, and annual corporate sponsorships ranging from $35,000 to $150,000 from local hospitals and businesses, the coalition launched a Safe Communities initiative with a 52-member community advisory panel. 3200 Four Components of Health Care Health Systems & the Factors affecting Health Care Delivery Goals of a Consumer Bill of Rights and Responsibilities Abbreviations and computer systems in health care How Social Movements Impact Society Non-profit organization: Bill & Melinda Gates Foundation Marketing Plan The patient-centered medical home (PCMH) model is one such model that aims to deliver coordinated, accessible healthcare to improve outcomes and decrease costs. 1996. By almost any metric, uninsured adults suffer worse health status and live shorter lives than insured adults (IOM, 2002a). Health care is a priority and source of concern worldwide. Vignettes drawn from the experience of American Hospital Association NOVA Award recipients illustrate the importance of investing in overall community health (AHA, 2002). 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. 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. This oversight is often reflected by health insurance coverage restrictions that exclude oral health care. In a random survey of emergency department directors in 1998 and 1999, 91 percent of the 575 respondents reported overcrowding problems (Derlet et al., 2001). 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. 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. OPM (Office of Personnel Management). Second, they are the principal providers of specialized services and serve as regional referral centers for smaller towns or cities and rural areas. Distribution (percent) of Sources of Payment for Mental Health/Substance Abuse Treatment, by Type of Use, 1996. Schoenbaum M, Untzer J, Sherbourne C, Duan N, Rubinstein LV, Miranda J, Carney MF, Wells K. 2001. Inequities in health services among insured Americans: do working-age adults have less access to medical care than the elderly? 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. The number of eligible children fell by more than half a million between 1995 and 1996. To realize the full potential of the NHII, supportive changes in the social, economic, and legal infrastructures are also required. 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. 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., 1990; Mandelblatt et al., 1999; Zambrana et al., 1999; Wagner and Guendelman, 2000; Breen et al., 2001; O'Malley et al., 2001). Termination from Medi-Cal: does it affect health? However, reimbursement policies for primary care do not support the services necessary to provide evidence-based care for depression (Wells et al., 2000; Schoenbaum et al., 2001). 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). 1996. 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. Fiscal year 2002, Sustaining community health: the experience of health care system leaders. The health care sector also includes regulators, some voluntary and others governmental. Adequate population health cannot be achieved without making comprehensive and affordable health care available to every person residing in the United States. Cost sharing is an effective means to reduce the use of health care for trivial or self-limited conditions. 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). Three levels of Health Care Primary Secondary Tertiary Primary Care Goal: To decrease the risk to a client (individual or community) of disease or dysfunction. . 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, 2000a). Health care delivery forms the most visible function of the health system, both to patients and the general public. More than 80 percent of uninsured children and adults under the age of 65 lived in working families. 2001. Boufford (1999) has suggested a Community Health Improvement Strategy that identifies a number of steps that provider organizations can take in such community-based efforts (see Box 59). 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. A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This may be because of cost concerns or insurance plan restrictions or simply professional judgment that the test is unnecessary for appropriate clinical care. U.S. Department of Housing and Urban Development. Although changes in the Medicaid program continue to challenge Denver Health, it continues to balance its broad responsibilities to the public's health with its role and capacity as a large health care provider. The emergency departments of hospitals in many areas of New York City routinely operated at 100 percent capacity (Brewster et al., 2001). The move from traditional fee-for-service care models to new payment and delivery models dictates that physicians reevaluate how quality measures and payments are linked to outcomes. 2000. Having a regular source of care improves chances of receiving personal preventive care and screening services and improves the management of chronic disease. In particular, managed care rules have changed to allow increased coverage of care provided in emergency departments. Among physicians, about 3 percent are African American, 2.2 percent are Hispanic, and 3.6 percent are Asian (AAMC, 2000). Cagney KA, Kerner J. The aging of the population means an increase in the number of patients who require skilled care for chronic diseases and age-related conditions, but the growth in the pool of nursing professionals is not keeping pace with the growth in the patient population. Needleman J, Buerhaus PI, Mattke S, Stewart M, Zelevinsky K. 2001. Johnson R, editor; , Morris TF, editor. Enable all citizens to obtain needed health care services. 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.