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68 Cards in this Set
- Front
- Back
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Names problems in healthcare
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(1) inexplicable contradictions in objectives (prevention vs. intervention); unwarranted variations in performance, ineffectiveness (lack of evidence), and inefficiency (overuse & duplication); and long standing difficulties in relationships with public and government
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Strategies for addressing cost, access and quality
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60's catered to elderl and low income with no regard for cost; 70's-80's push to control costs, then focused on availability, then quality; the 90's reforms were superseded by emergence of MCO's (main focus being controlling cost - concern that americans' needs were not being met)
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Eli Ginzberg
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NE Journal of Medicine stated that as long as the dominant groups could not agree, we will continue to temporize. "unwilling to risk the strengths of our existing health care system in a radical effort to remedy admittedly serious deficiencies."
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"Natural history of a disease" as tracked by epidemiologists
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use matrix for putting everything known about a disease or condition in the sequence of its origin and progression when untreated
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How are they tracked
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many diseases (especially chronic) may last for decades, have irregular evolution and extend through sequence of stages. When cause of stages are defined, they can be matched against interventions intended to prevent or arrest it's progress
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Levels of preventnion?
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Primary, Secondary, Tertiary
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What is health promotion?
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health education, good standard of nutrition; personality development; adequate houseing, recreation and agreeable working conditions; marriage counseling and sex education; genetics; selective examinations
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What is specific protection?
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immunizations; personal hygiene; environmental santiation; protection from occupational hazards and accidents; use of nutrients; protection from carcinogens; avoidance of allergens
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Two parts to the natural history of any disease
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Prepathogenesis period and period of pathogenesis
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Prepathogenesis period
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Agent--host & environmental factors....known and unknown that bring agent and host together or produce a disease provoking....stimulus in the human host
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Period of pathogenesis
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interaction of host/stimulus; host reaction....stimulus/agent becomes established and increases by multiplication or increment; tissue and physiologic changes; signs/symptoms; illness...leads to recovery and then ends or disability; defect; chronic state; death
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Primary Prevention Period includes.....
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Health Promotion and Specific Protection
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Secondary Prevention includes.....
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Early Diagnosis and Prompt Treatment
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Tertiary Prevention includes...
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Disability Limitation; Rehabilitation
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What is included in early diagnosis and prompt treatment?
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case finding measures
screening surveys selective examinations objectives: cure and prevent disease processes; prevent spread of communicabe diseases; prevent complications and sequelae; shorten period of disability |
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What is included in disability limitation?
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adequate treatment to arrest the disease process and prevent further complications and sequalae; provision of facilities to limit disability and prevent death
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What is included in Rehabilitation?
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provision of hosptial and community facilities for retraining and education for maximum use of remaining capacity; education of the public and industry to utilize rehabilitated; full employment as possible; selective placement; work therapy; sheltered colony
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What are the stages in the Natural History of Aging?
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Prepathogenesis period (health promotion & specific protection) and Period of Pathogenesis (early diagnosis and treatment; disability limitation; rehabilitation; long-term support)
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What are the agent, environmental and host factors related to aging?
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sunlight, radiation, carcinogens, biological; housing, physical risks; age, race, gender, heredity and familial, culture, occupational, behavioral
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What are the steps in the Natural History of Aging?
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factors--interaction--physiologic and/or mental changes; physical and/or mental deterioration illness, accident, signs, symptoms--can result in clinical recovery, death, or progression to chronic condition including decreased body strength, coordination, blanace, dexterity, cognition--then chronic stages until death
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Health promotion in aging includes....
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health education; wellness promotion; nutrition; exercise; adequate housing; avoiding alcohol, drugs, and tobacco; stress reduction
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Specific protection in aging includes....
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immunization; personal hygiene; driver's education; seat belts; accident protection; reduction of risk factors--cholesterol, weight, etc.
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Early diagnosis and treatment in aging includes....
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periodic physicals; self-examination; primary care centers for older adults; mental health counseling; precentative care/scressing centers; acute care
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Disability limitation in aging includes....
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subacute care; hearing and vision svcs; convalescent care; psychiatric care; home care; home based chemo; personal emergency response; housing for older adults
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Rehabilitation in aging includes....
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Physical and psychological rehab.; cardiac and stroke rehab; inpatient and outpatient; home care
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Long term support includes....
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social and medical models; adult day care; congregate dining; institutional and noninstitutional skilled nursing care; assisted living with board and care; personal svcs for ADL's; home care; MOW; DME; transportation; homemaking; home modifications; hemodialysis; respiratory, etc.
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Major stakeholders in US Healthcare industry
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public; employers; providers; hospitals (and other health care facilities); government; alternative therapies; MCO's (and other insurers); long-term care; mental health; voluntary facilities and agencies; health professions education and training institutions; professional associations; other health industry organizations; research communities
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Why are stakeholders important?
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shared and conflicting concerns, interests, and influences of these constituent groups cause them to shift alliances periodically to oppose or champion specific reform policies
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Public
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first and foremost among stakeholders; patients ..... consumers of services. General agreement that some form of basic health care svcs should be available to all citizens. Consumer Organ. that support public are Am Assoc. of Retired Persons, Am CA Society, Am Heart Assoc.
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Employers
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increasingly influential group; paying for higher proportion of costs; taking more proactive role in determining benefits; employer organizations wield considerable political power in Congress
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Providers
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core of the industry; have most to do with actual process and outcomes of svcs provided; responsible for quality and to a large extent the cost of healthcare
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Hospitals and other health care facilities
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provider activity shaped by availability and nature of health care institutions; central to the existing health care system; hospitals are but one component in delivery (nursing homes, SNF's, medical practices, and MCO's)
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Government
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dominant authorities over the system since MC/MA; serve as payers, regulators and providers (VA)
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Alternative Therapies
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contribute significantly to the amt., frequency and cost of health care; 1 in adults use alternative forms of health intervention each year - more visits made to alt. care providers than to PCP's; $10 billion/yr spent (rolfing, yoga, spiritual healing, relaxation techniques, herbal remedies, energy healing, chiropractic; Ins. and MCO's now considering alt. therapies
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Insurers paying for alt. therapies???
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1995 lger insurance companies started paying for selected unconventional therapies for heart disease and other chronic conditions; Am Hosp. Assoc. survey 15% of US hosp have opened alt or complimentary medicine centers by 2000
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Managed care organizations
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long been major stakeholder; Clinton healthcare reform killer; MCO's and economic pressures of capitated fees have produced much of the change occcurring in the regional systems of healthcare
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Long term care
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NH, HHA, Rehab., SNF's becoming increasingly important; continuum of services required for the more complex care of aging patients
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Mental Health
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often neglected in debates over reform; critically impt to effectivenss of the health care system; do not generate the same concern and unprejudiced funding
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Voluntary facilities and agencies
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not-for-profit; suggested as the safety net to replace the svvcs to be eliminated in cost cutting proposals
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Health professions education and training
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schools of public health; medicine, nursing, dentistry, pharmacy, optometry, allied health impace nature, quality and cost of health care; schools influence values, attitudes, and ethics that govern practitioners
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Professional Associations
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considerable influence over legislative proposals, regulation, quality issues, and other political matters; lobbying of AMA is legendary; American Nursing Assoc, Am Hosp. Assoc. Am Dental Assoc.
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Other health industry organizations
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commercial entities; insurance and pharmaceutical enterprises, medical supplies, consulting and information and mgmt system suppliers
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Research communities
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national research enterprise; NIH and Agency for Healthcare Research and Quality exert tremendous influence over health care research and practice (investigations that serve policy decision making and define kinds of research allowed)
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Managed care
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links financing and service delivery and payers have significant control over how and what svcs are provided; provider panel; limited choice; gatekeeping; risk sharing; quality mgmt and UR; HMO's/PPO's; provider economically accountable to payor
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Problems with rural health networks
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often incomplete, shortages of various services and duplications of others; hosp. having difficulty continuing acute inpt. svcs; major employer; lose staff; high morbidity/mortality in elderly and infants; costs increasing and population is declining in rural health; shift from inpatient to outpatient services
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Attempts to promote development of rural healthcare systems
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strive to provide local access to primary, acute, and emergency care; links to reg. specialists and tertiary care svcs; (1991)essential access community hosp. and rural primary care hosp. (relaxed regs - PA's, NP's providing inpatient care without physician in house); 1997 Rural Hosp. Flex. Prog. put Critical Access Hospital (CAH)- many of same features previously implemented-increases beds from 6 to 15 with max LOS changing from 72 to 96 hours; maintenance of 25 beds with swing bed prog.; telemedicine
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Other health industry organizations
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commercial entities; insurance and pharmaceutical enterprises, medical supplies, consulting and information and mgmt system suppliers
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Research communities
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national research enterprise; NIH and Agency for Healthcare Research and Quality exert tremendous influence over health care research and practice (investigations that serve policy decision making and define kinds of research allowed)
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Managed care
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links financing and service delivery and payers have significant control over how and what svcs are provided; provider panel; limited choice; gatekeeping; risk sharing; quality mgmt and UR; HMO's/PPO's; provider economically accountable to payor
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Problems with rural health networks
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often incomplete, shortages of various services and duplications of others; hosp. having difficulty continuing acute inpt. svcs; major employer; lose staff; high morbidity/mortality in elderly and infants; costs increasing and population is declining in rural health; shift from inpatient to outpatient services
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Attempts to promote development of rural healthcare systems
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strive to provide local access to primary, acute, and emergency care; links to reg. specialists and tertiary care svcs; essential access community hosp. and rural primary care hosp. (relaxed regs - PA's, NP's providing inpatient care without physician in house)
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Aging impact over time
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rate of aging 5x's that of overall population; estimated 30% of pop will be over 65 by 2050, 85 y.o's will dbl, but under 35 will decline by 10%; 85 and older pop will go from 4 to 19 million by 2050
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Other factors impacting healthcare besides elderly
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technology development and workforce shortages (Uwe Reinhardt)
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How does culture impact future healthcare?
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lg. population gains in Asian and Hispanic elderly btwn 1980-1990 and will increase substantially in future decades; hispanic pop growing much faster than black; by 2050 hispanics will exceed # of older blacks by 25%; non-hispanic white will drop from 83.5% to 64.2%
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Problems with increased number of elderly?
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burden of incurable chronic diseases; intensity of care required by frail older adults; increased cognitive needs; lack of healthcare workers who are culturally sensitive and specialize in geriatrics; BBA of 1997 addressed all-inclusive care for elderly; long term care needs - not addressed by MC or private insurance
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Connection between interest groups and health care
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lobbying by interest groups for or against initiatives; pressure from supporters and opponents of health care system changes; well-financed special interest groups; former congressional staffers on payroll of private interest groups and former lobbyists assume positions on Capitol Hill; $$$ significant amt. spent to defeat the Clinton Health Security Act
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Groups playing key role in debate on tax-funded health services
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providers, insurers, consumers, business, and labor
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Most powerful lobbyist?
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Traditionally physicians. Still one of the best financed and most effective, now several different medical lobbies exist as result of political differences
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American Medical Association (AMA)
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est. 1847 to improve medical education; lgest medical lobby(287,000 members); hx of opposition to govt control and advocates for physician autonomy; ht of power from 40's-70's; Sammons, AMA Exec. VP in 1980's alienated many members of Congress in opposition to MC cuts; 1989 Todd took over as exc. VP and restored Congressional relations; included and supported Clinton plan of access to healthcare for all Americans; cost containment, malpractice reform, and physician autonomy still remain areas of contention
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Other Physician Groups
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American College of Physicians; American Academy of Family Physicians; American Society of IM; American College of Surgeons AHA has decreased in size and influence but is regaining from setback in 80's when it lost against Reagan's proposal of MC PPS. It has never regained power it had in 1970's
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Other hospital groups
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AMA est. 1898 (42,000 members); Federation of American Health Systems (FAHS) est. 1966 "for-profit" (1400 members)-opposed govt controlled price controls; Catholic Health Association est. 1915 (smallest 700 hosp. 300 NH's)
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American Nurses Association
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est. 1896 (200,000 members) nurses not politically active until around 1980; endorsed Clinton plan in 9-93 and earned several concessions, including eliminatin of state restrictions of scope of practice, direct MC reimbursement, and doubling of federal support for training
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Insurance Companies
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Health Ins. Assoc. of America est 1956; Group Health Assoc. of American est 1959; BC/BS Assoc. est 1946 - encompasses 69 organizations and typically serve higher risk ppl in pool of 70 million (supported Clinton); Grp. Health Assoc. of America (1,100 members)
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Consumer Groups
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American Assoc. of Retired Persons (AARP) est. 1958 (35 million members); Patients' Coalition of 50+ major national not-for-profit health organ (coalitions unite many organizations to gain influence and clout with legislators)
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Business and Labor
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Nat'l Federaton of Independent Businesses est 19433 (570,000) lgest rep of small firms; Nat'l Assoc. of Manufacturers est. 1895 (12,500) interests of lg. employers; US Chamber of COmmerce est 1912 (200,000); Chamber & Manufactures welcome equalizing effect of an employer mandate but wary of intense govt regulation; American Federal of Labor and Congress of Industrial Organization (AFL-CIO) (14 million) connected with lgest health care union Service Employees International Union
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Pharmaceutical Industry
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1997-1999 spent $235.7 mil to lobby Congress and executive branch. Hired one lobbyist for every 2 members of congress; campaign contributions increased 147%; drug costs now more than hospital care; lg role in crafting MC Part D; doughnut hole impacting middle class and disabled retirees who do not qualify for poverty assistance but are on fixed incomes
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Public Health focus on prevention
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American Public Health Assoc est 1872; focus on health promotion and disease prevention; influence strongest on democratic administrations
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Values and Assumptions that guide priorities
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1990 plan Healthy People 2000: nat'l plan to reduce preventable deaths, disabilities, and diseases; goals out of reach due to lack of personal and provider accountability; self-indulgent values precludes responsibility for larger society good; 85% of 2000 goals unmet and 2010 goals are unrealistic
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