Health Services Midterm Flashcards
Healthcare system objectives
- To enable all citizens to receive health
care services (aka ACCESS). - To deliver services that are cost effective
and meet established standards of quality.
Health (WHO)
state of complete physical,
mental, and social well-being, not just
absence of disease. Relates to access to
medical care and individual needs.
Public health
the set of activities a
society undertakes to monitor and improve
the health of its collective membership
Public Health Mission
Fulfilling society’s interest in assuring the
conditions in which people can be healthy.
Its aim is to generate organized
community effort to address the public
interest in health by applying scientific and
technical knowledge to prevent disease
and promote health.
Institute of Medicine (IOM)
Key Differences?
Medical Care VS. Public Health
Look in Textbook
Basic Healthcare Delivery Functions
Financing, Insurance, Delivery, Payment
Financing and Insurance Mechanisms
Employer-based health insurance – (private) • Privately-purchased health insurance – (private) • Government programs (public) – State Employees Group • employees – Medicare • elderly and certain disabled people – Medicaid and CHIP • indigent, poor (if they meet the eligibility criteria), children
Characteristics of a free market healthcare system
• Multiple patients (buyers) & providers (sellers)
act independently
• Unrestrained competition occurs based on price
& quality
• Patients have information about all available
services, and provider price & quality info
• Patients directly bear costs of services
• Patients as consumers make decisions about
HC services
Why is the US healthcare market
referred to as “imperfect”?
See text discussion #7
10 Characteristics that Differentiate
the U.S. Health Care System
- No central agency governs a system
- Access is selective based on insurance
- Health care offered under imperfect market activity
- Third party insurers are intermediaries between
finance and delivery - Multiple payers are cumbersome
- Balance of power, no domination
- Legal risk affects practice behavior
- New technology creates demand for its use
- New service settings along a continuum
10.Quality is achievable
Why are some US citizens without
health insurance?
See text discussion #5
Our System is fraught with
– duplication – overlap – inadequacy – inconsistency – waste – complexity – inefficiency – financial manipulation – Fragmentation
Triple Aim
- improving the experience of care
- improving the health of populations
- Reducing per capita costs of health care
Why is it important for healthcare
managers and policymakers to understand
the delivery system?
See text discussion #11
In the U.S. Health Care System there’s little or no:
–networking –interrelated components –standardization –coordination –cost containment as a whole –planning, direction
The Blended Public and Private
U.S. Health Care System results in:
– multi financial arrangements
– many insurance company with different risk
mechanisms
– many payers
Why is cost containment an elusive goal
in US?
See text discussion #1
Very Brief History
of U.S. Health Care and PH - Eras
• Pre-industrial – Pre 1850 – 1850 -1900 • Industrial – 1900 – World War II – World War II – 1980 • Coprorate – 1980s - now
External Forces Affecting Healthcare Delivery
- Social values and culture
- Political Climate
- Global Influences
- Economic Conditions
- Population Characteristics
- Technology Development
- Physical Environment Figure 1-2
Prior to 1850
• 14th c. Epidemics - Black Death (plague),
leprosy, cholera, etc – were accepted parts of
life, with no collective response to infectious
diseases possible.
• Age Enlightenment (17-18th c.) start to question
accepted beliefs, expand knowledge of science
• Industrial Revolution ~1790-1860
Urban crowding, unsafe/unsanitary living and
working conditions pandemics
Massachusetts Bay Colony
• 1639 – Mass. Bay Colony required births and deaths be registered • 1647 – Passed regulation to prevent pollution in Boston Harbor • Smallpox killed several colonies, but by 18th c. sick patients isolated, ships quarantined.
Marine Hospital Service
• 1798 Pres. John Adams: bill law U.S. Public Health Service Act - Creates Marine Hospital Service to care for sick/injured merchant seamen in American ports 1870: Reorganized loose network locally controlled hospitals centrally controlled –Washington, D.C. – Supervising Surgeon Surgeon General
What happened in 1850
• Lemuel Shattuck’s Report of the Sanitary
Commission of Massachusetts, 1850 outlined
current/future PH needs for state
been called the “bible”
became blueprint for American PH system
– Called for state and local health departments to be
established, happened a few decades later
• Sanitary inspections, communicable disease
control, food safety, vital stats, services for kids
Building PH Infrastructure
• 1878-9: National Port Quarantine Act
– Made federal government responsible for identifying and
dealing with disease outbreaks current PHS, CDC
• 1910 Flexner Report on medical ed/schools,
“profession” begins. AMA control licensing.
• 1912: Marine Hospital Service PH Service
– with broader responsibilities
• 1922: Sheppard-Towner Act (MCH)
• 1929: First pre-paid group practice
• 1930: NIH established
Infrastructure, cont
• 1930s: FDR and the New Deal era
– PH Service supported by Congress, expanded
• 1935: Social Security Act, cash assist
programs
• 1939-45 WWII –need more hospitals, docs
• 1946 Hill-Burton = Hospital Survey and
Construction Act, built lots of hospitals with
fed govnt paying half construction cost
• 1946: CDC created
1950-60s
Filling gaps in med care delivery
• 1950s - advances in medical technology, more
interest in health insurance, docs as solo
practitioners
• Rising demand, rising premiums
• 1953 – fed Dept Health, Educ & Welfare
• LBJ War on Poverty
• 1960 Kerr Mills Act – funding for voluntary state
Medicaid-like programs to cover aged poor, but
not much state participation
• 1964 Excess capacity, Hill Burton shifts to
modernizing facilities instead of building
1965
• MEDICARE & MEDICAID CREATED
– Officially, Title XVIII and XIX respectively
– Part of President Johnson’s “Great Society”
– Expand social insurance
– Start to recognize personal medical care as
part of public health
– To be examined in greater depth near the end
of the term (Section IV topics)
1970s
• Certificate of Need (CON) laws – Too many hospitals (Hill Burton folds) • National Health Service Corp – shorter length of stay, more ambulatory care • 1973 – HMO Act - mandatory dual choice – Competition instead of regulation • 1974 - Health Planning and Resource Development Act
1980s
• Too many docs, specialists; not in right
place oversupply and maldistribution
• Managed Care takes off
• High health care costs
• Start to care more about assessing quality
– 1986: National Practitioner Data Base (NPDB)
started
– 1987: create Nursing Home datasets
1990s – 2000s
• Demographic shift Population aging
• Hospital not center of HC; part of system
• Reimbursement changes (to contain costs)
• Welfare to Work programs
• 1997 Balanced Budget Act (BBA)
– SCHIP
– Medicare + Choice
• 1999: More diverse health staff practicing -
NPDB includes other medical staff
• 2006: Medicare Part D – prescription drugs
Examples of 21st c.
Public Health Threats (Table 6.1)
Terror/Natural Disasters/Disease
Active attacks/Earthquakes/Anthrax
Economic attacks/Tsunamis/Avian Influenza
Commerce/Hurricanes/Botulism
Interfer w/food, water, etc./Wildfires/ Ebola & hemorrhagic fever
Internet/Floods/Hantavirus
Recap PH lessons from history
• 1st organized PH activities in local seaport
villages and focused on problems in those
communities, later expanded to state/fed.
• Focus on infectious chronic diseases
• Categorical disease-specific approach
Trends last few decades
• Acute care primary care • Illness wellness • Independent institutions integrated systems • Inpatient outpatient • Individual health community wellbeing • Fragmented care managed care • Service duplication continuum of services
Biomedical Model
- The existence of an illness or disease
- Seek and use care
- Find relief of symptoms and discomfort
- Diagnosis of illness and treatment of disease to
restoration - Once relief is obtained, the person is considered well,
whether or not the disease is cured
Implications of the Biomedical Model
See book
Public Health Mission
Fulfilling society’s interest in assuring the
conditions in which people can be healthy.
Its aim is to generate organized
community effort to address the public
interest in health by applying scientific and
technical knowledge to prevent disease
and promote health.
Institute of Medicine (IOM)
PUBLIC HEALTH &
PREVENTION
Anticipatory action taken to reduce the possibility of an event or condition occurring or developing, or to minimize the damage that may result from the event or condition if it does occur.
Wellness Model
Efforts and programs that prevent disease and
optimize well-being
Three factors that the Wellness Model is built on
1) understand risk factors
• done through a health risk appraisal
• when known, interventions can take place
2) intervention
• behavior modifications
• therapeutic (primary, secondary, tertiary
prevention)
3) adequate public health and social services
Therapeutic Preventions
• Primary: activities to decrease or restrain the
problem or develop that a disease will occur
– Smoking cessation to prevent lung disease
– Handwashing to decrease spread of infection
• Secondary: early detection and treatment of
disease to block progression of disease or injury
– Pap smears, mammograms, prostate exams
• Tertiary: rehabilitation and monitoring to prevent
further injury or complications
– Turning bed-bound patients
Blum’s Force Field & Well-being
Paradigms of Health
Force Fields:
– Environment
• Physical, social, cultural, and economic factors
– Lifestyle
• Behaviors, attitudes toward health
– Heredity
• Current health and lifestyle practices are likely to
impact future generations
– Medical care
• Health care delivery system (access, availability of
service)
Healthy People 2020
Healthy People provides science-based, 10-year
national objectives for improving the health of all
Americans. For 3 decades, Healthy People has
established benchmarks and monitored
progress over time in order to:
- Encourage collaborations across sectors.
- Guide individuals toward making informed
health decisions.
- Measure the impact of prevention activities.
Healthy People 2020 Mission
• Identify nationwide health improvement priorities.
• Increase public awareness and understanding of the determinants of health,
disease, and disability and the opportunities for progress.
• Provide measurable objectives and goals that are applicable at the national,
State, and local levels.
• Engage multiple sectors to take actions to strengthen policies and improve
practices that are driven by the best available evidence and knowledge.
• Identify critical research, evaluation, and data collection needs.
Healthy People 2020 Goals
• Attain high-quality, longer lives free of preventable disease, disability, injury,
and premature death.
• Achieve health equity, eliminate disparities, and improve the health of all
groups.
• Create social and physical environments that promote good health for all.
• Promote quality of life, healthy development, and healthy behaviors across
all life stages.
New for 2020
• Adolescent Health
• Blood Disorders and Blood Safety
• Dementias, Including Alzheimer’s Disease
• Early and Middle Childhood
• Genomics
• Global Health
• Healthcare-Associated Infections
• Health-Related Quality of Life and Well-Being
• Lesbian, Gay, Bisexual, and Transgender Health
• Older Adults
• Preparedness
• Sleep Health
• Social Determinants of Health LHI: Increase the proportion of
students who graduate with a regular diploma 4 years after starting
9th grade
HP 2020
Foundational Health Measures
- General Health Status
- Health-related quality of life and wellbeing
- Determinants of health
- Health disparities
- General Health Status Measures
Life expectancy Healthy life expectancy Years of potential life lost (YPLL) Physically and mentally unhealthy days Self-assessed health status Limitation of activity Chronic disease prevalence
Physical Health Measures
Morbidity
Mortality/Longevity
Disability
- Health related quality of life
• domains related to physical, mental, emotional and social functioning • IMPACT of disease on HRQoL • Select examples – Pain – Satisfaction with relationships – Emotional distress
- Determinants of health
• The range of personal, social, economic, and environmental factors that influence health status are known as determinants of health. • Determinants of health fall under several broad categories (HP 2020): – Policymaking – Social factors – Health services – Individual behavior – Biology and genetics
- What are “health disparities”?
Health disparities are differences in the
incidence, prevalence, mortality, and
burden of diseases and other adverse
health conditions that exist among specific
population groups in the United States.
– NIH Strategic Plan to Reduce and Ultimately
Eliminate Health Disparities, 2001
Language of health disparities
• “Disparities” is typical U.S. term
• “Variations” is sometimes used in England
• “Inequalities” is common in Europe
All generally refer to differences
The Equitable Distribution of Health
• We have scarce resources. 1. How much health care should be produced? 2. How should health care be distributed? – Distribution creates inequalities – Need justice and fairness
Theories of Equitable Distribution
Two Contrasting Principles: – Market Justice • The Economic Good – Social Justice • A Social Good
How is HC rationed
in a market justice vs social justice
system?
Review question 12
Characteristics/Implications Market Justice
Book
Characteristics/Implications Social Justice
Book
Health Services Utilization Specific
measures
– # visit in last year/total population
– Report % or avg visits per person per year
– Can specify type of care or provider seen
Health Services Utilization Institution-Specific measures
– Occupancy rate or average daily census
– ALOS
5 A’s OF ACCESS
- Accessibility
- Acceptability
- Accommodation
- Affordability
- Availability
Medical Home
• Patient-centered • regular source of (primary) care • Key features of primary care – Accessibility – Comprehensiveness – Continuity – Coordination – Accountability
NHIS Stands For
National Health Interview Survey
CHIS Stands For
CA Health Interview Survey
NHANES Stands for
National Health & Nutrition Examination Survey
HHANES stands for
Hispanic Health and Nutrition Examination Survey
CDPH stands for
CA Dept of Public Health
Fertility Trends
• Peak childbearing is between 25-29 years
• Fertility has shifted to an older group of
women for the majority of child bearing
• Percentage of live births to unmarried
women has greatly increased since 1970.
– Overall one-third of all births are to unmarried
women in the United States
Life Expectancy is
• Life expectancy at birth = the number of years of
life expectation upon birth.
• Life expectancy varies from country to country,
but country differences are more moderate by
age 65.
• Females live significantly longer than males
• Life expectancy at 65 years = the number of
additional years of life expected once an
individual reaches 65 years.
US Infant Mortality Rate
7.1 in 1999, 6.1 in 2011
IMR US Ranking 2011
175 (#5 lowest number of deaths)
TOP 10 KILLERS (2009 final)
- Heart disease
- Malignant neoplasms (cancers)
- Chronic lower respiratory diseases
- Cerebrovascular diseases (strokes)
- Accidents/Unintentional injuries
- Alzheimer’s disease
- Diabetes mellitus
- Influenza and pneumonia
- Nephritis, nephrotic syndrome and nephrosis (kidney)
- Intentional self-harm (suicide)
Cancer survival rates are impacted by numerous
factors including
detection, treatment,
compliance, and technology
Motor Vehicle Accidents
• An estimated 40,000 people are killed and
approximately 2,000,000 are injured
annually in vehicle-related accidents.
• Vehicular mortality is substantially higher
for males (of all ages) than females.
• Vehicular mortality has declined over time
but remains inexcusably high.
Chronic Disease Prevalence
• Chronic diseases are the leading cause of death and
disability in the US causing 7 out of 10 deaths each year.
Heart disease, cancer, and stroke alone cause more
than 50 percent of all deaths each year.
• In 2008, 107 million Americans—almost 1 out of every 2
adults age 18 or older—had at least 1 of 6 reported
chronic illnesses:
• Cardiovascular disease
• Chronic obstructive pulmonary disease (COPD)
• Arthritis
• Diabetes
• Asthma
• Cancer
The Structure of
Organized Public Health Efforts
3 levels of govnt (fed, state, local) each play
different roles in each of 3 major goals:
• Assessment - Know what needs to be done
• Policy development - Being part of the solution
• Assurance - Make sure it happens
Assessment
- Surveillance
- Identifying the public’s needs
- Analyzing the causes of problems
- Collecting and interpreting data
- Monitoring and forecasting trends
- Research
- Evaluation of outcomes
Policy Development
- Establishing specific goals
- Developing ways to achieve these goals
- Allocating resources
Assurance
• Ensures that necessary services are provided in order to reach established goals. • Involves implementation of legislative mandates and the maintenance of statutory responsibilities.
Federal Government
Public Health Activities
- Documenting health status in the U.S.
- Sponsoring research on basic and
applied sciences (NIH) - Formulating national objectives and
policy (like Healthy People 2020) - Setting standards of performance of
services and protection of the public - Providing financial assistance to state and local governments to carry out predetermined programs.
- Ensuring that personnel, facilities, and other technical resources are available to carry out national priorities.
- Ensuring public access to health care
services. - Providing direct services to certain subgroups of the population.
Federal Health Bureaucracy Key agencies
– Department of Health and Human Services
(DHHS)
– Department of Veterans Affairs (VA)
• Provides comprehensive care to veterans who
were not dishonorably discharged
– Department of Defense (DOD)
• TriCare Provides health insurance to current and
retired military personnel and their families
THE DEPARTMENT OF HEALTH AND
HUMAN SERVICES is…
the United States
government’s principal agency for protecting
the health of all Americans and providing
essential human services, especially for
those who are least able to help themselves.
DHHS Facts
• HHS REPRESENTS ALMOST A QUARTER OF ALL FEDERAL
OUTLAYS, and it administers more grant dollars than all other federal
agencies combined. HHS’ Medicare program is the nation’s largest health
insurer, handling more than 1 billion claims per year. Medicare and
Medicaid together provide health care insurance for one in four Americans.
• HHS WORKS CLOSELY WITH STATE AND LOCAL GOVERNMENTS
• 300+ HHS programs are administered by 11 operating divisions
• In addition to the services they deliver, the HHS programs provide for
equitable treatment of beneficiaries nationwide, and they enable the
collection of national health and other data.
• HHS Budget, FY 2008 – $707.7 billion
• HHS employees – 64,750
ACF stands for
Administration for Children and Families
AoA stands for
Administration on Aging
AHRQ stands for
Agency for Healthcare Research and Quality
CDC stands for
Centers for Disease Control and Prevention
CMS stands for
Center for Medicare and Medicaid Services - $606.9 billion largest portion of budget (FY08)
FDA stands for
Food and Drug Administration
HRSA stands for
Health Resources Services Administration
IHS stands for
Indian Health Services
NIH stands for
National Institutes of Health
SAMHSA stands for
Substance Abuse and Mental Health Services Admin.
ATSDR stands for
Agency for Toxic Substances and Disease Registry
Newest member of the DHHS family is…
Office of the Assistant Secretary for
Preparedness and Response (ASPR)
Current DHHS Secretary
Kathleen Sebelius • country’s highest-ranking health official • member of the President’s cabinet • powerful voice for reforming our health system
Current Surgeon General
• Vice Admiral Regina M. Benjamin, M.D., M.B.A. • “America’s doctor” • Provides best scientific evidence on health issues • Appointed by President (Senate consents)
Principal governmental entity responsible
for the active protection of the public’s
health in the United States
State Government Police Power – power to enact and enforce laws to protect and promote the health and safety of the people PH 648 Health Policy
State Government
Public Health Activities
1. Collecting and analyzing health statistics to determine the health status of the public. 2. Providing general education to the public on matters of public health importance. 3. Maintaining state laboratories to conduct certain specialized tests required by state law. 4. Establishing and enforcing public health standards for the state. 5. Granting licenses to health care professionals and institutions and monitoring their performance. 6. Establishing general policy for local public health units and providing them with financial support.
Local Government
Public Health Activities
• Local health departments are the front line of
public health services.
• These departments are directly responsible for
carrying out the policies and strategies decided
upon by federal and state agencies.
1. Vital statistics
2. Communicable disease control
3. Environmental sanitation
4. Maternal and child health
5. Health education of the public
What is Medical Technology?
• The application of scientific and technical knowledge that results in improved medical care • It includes both human and nonhuman inputs used in the production and management of medical goods and services Examples: Biomed, HIT, Durable/Non-durable, Pharma
Information Technology (IT)
• IT deals with the gathering, storage,
analysis, and transformation of data so it
becomes useful information for health care
professionals, managers, payers, and
patients
IT Applications
- Clinical information systems
- Administrative information systems
- Decision support systems
Management Uses of IT Outputs
- Evaluate financial performance
- Measure utilization of services
- Assess clinical quality
- Determine trends in health care delivery
- Control costs
- Improve productivity
- Strategic planning
- Demand assessment
Health Informatics
• IT application – requires IT, goes further –
applies info science to improve efficiency,
accuracy, and reliability of HC services
