The Foster G. McGaw Prize for Excellence in Community Service is awarded by the American Hospital Association to recognize hospitals that have distinguished themselves through efforts to improve the health and well-being of everyone in their communities. (Eds.). Heffler S, Smith S, Won G, Clemens MK, Keehan S, Zezza M. 2002. In that same year, $6.4 billion was spent on treatment. Federal Supplementary Medical Insurance Trust Funds. NACCHO (National Association of County and City Health Officials). The health care delivery system as it exists today cannot deliver those elements. 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). The committee is concerned that with the escalation of expenditures, going in large measure toward maintaining current services, it will be difficult to identify the necessary public- and private-sector resources that will be needed for new activities. In particular, managed care rules have changed to allow increased coverage of care provided in emergency departments. Mental disorders are a major public health issue because they affect such a large proportion of the population, have implications for other health problems, and impose high costs, both financial and emotional, on affected individuals and their families. Public sources provide more than two-thirds of the funding for alcohol and drug treatment facilities. Concierge medicine, according to Healthline, is a new healtchare delivery system that's quickly gaining traction. 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. As discussed in Unequal Treatment (IOM, 2002b), the factors that may produce disparities in health care include the role of bias, discrimination, and stereotyping at the individual (provider and patient), institution, and health system levels. Adults without health insurance are far more likely to go without health care that they believe they need than are adults with health insurance of any kind (Lurie et al., 1984, 1986; Berk and Schur, 1998; Burstin et al., 1998; Baker et al., 2000; Kasper et al., 2000; Schoen and DesRoches, 2000). Promote the consistency and equity of care through the use of evidence-based guidelines. The current shortage of RNs, particularly for hospital practice, is a matter of national concern because nursing care is critical to the operation and quality of care in hospitals (Aiken et al., 1994, 2001). Many health care settings lack basic computer systems to provide clinical information or support clinical decision making. (2001), citing the American Hospital Association (2001a). 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. HMO. Coverage Matters, This chapter has outlined the main areas in which the health care delivery system and the governmental public health agencies interface. Blendon RJ, Scoles K, DesRoches C, Young JT, Herrmann MJ, Schmidt JL, Kim M. 2001. Furthermore, non-academic community health centers also frequently have close ties to their communities, collaborating to assess local health needs, providing needed services, and supporting community efforts with research expertise and technical assistance in planning and evaluation. 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. Fiscal year 2002, Sustaining community health: the experience of health care system leaders. (more). 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. Schizophrenia affects at least an estimated 2 million Americans in any year (Regier et al., 1993), whereas the most prevalent affective disorder, major depression, has been reported to occur in 6.5 percent of women and 3.3 percent of men in any year (DHHS, 2000a). Consumers will be expected to shop for their own care with a medical spending account coupled with catastrophic benefits for very large expenses. Children's Preventive Health Care under Medicaid. Children without insurance are three times more likely than children with Medicaid coverage to have no regular source of care. Smith V, Ellis E, Gifford K, Ramesh R, Wachino V. 2002. A 1998 finalist for the Foster G. McGaw Prize for Excellence in Community Service co-sponsored by AHA, the Franklin Community Health Network (FCHN) in Farmington, Maine, took the lead in developing a coalition and providing seed money to start a Rural Schools Equity Campaign (AHA, 2002). Payment & Delivery Models. Medical screening. However, such plans have yet to assume a significant role in the insurance market, and few employers offer them as an alternative. Distribution (percent) of Sources of Payment for Mental Health/Substance Abuse Treatment, by Type of Use, 1996. Lasker RD, Health care delivery systems differ depend- ing on the arrangement of these components. It is also associated with having a regular source of care and with greater and more appropriate use of health services. 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. Explore the United States's healthcare . The environment in which AHCs operate has changed substantially over the past decade. 2002. 2. Finally, virtually all states have the legal responsibility to monitor the quality of health services provided in the public and private sectors. 1999. Reports of sentinel events have proved useful for the monitoring of many diseases, but such reports may be serendipitous and generated because of close clustering, unusual morbidity and mortality, novel clinical features, or the chance availability of medical expertise. U.S. Office of Management and Budget (OMB). An important opportunity was lost when insurance companies, health plans and health providers, and the state and federal governments saw managed care primarily as a cost-containment mechanism rather than a population-based approach to delivering comprehensive and effective health care services. 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. 1984. However, this valuable tool has not been well supported and, as noted earlier, suffers from issues of lack of timeliness and incomplete reporting, as well as complex or unclear reporting procedures and limited feedback from governmental public health agencies on how data are used (Baxter et al., 2000; Stagg Elliott, 2002). The evidence that insurance makes a difference in health outcomes is well documented for preventive, screening, and chronic disease care (IOM, 2002b). State health departments often have legal authority to regulate the entry of providers and purchasers of health care into the market and to set insurance reimbursement rates for public and, less often, private providers and purchasers. The result is poor disease management and a high level of wasted resources. As a result of decreasing demand for hospital services and a changing financial environment, hospitals in many parts of the country reduced the number of patient beds, eliminated certain services, or even closed (McManus, 2001). For example, traditional patterns of reporting may be lost as health care delivery shifts from inpatient to outpatient settings. 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. 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). The development of enhanced information technology and its use in hospitals, individual provider practices, and other segments of the health care delivery system are essential for improving the quality of care. Of the 22.9 million children eligible for the EPSDT program in 1996, only 37 percent received a medical screen through the EPSDT program. Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. Identify a defined population (community) and develop links to that community, Assess health status and need, and adjust the volume and types of services provided to respond to the health needs of the community, Develop effective intervention programs in partnership with the community, Address the health status of the institutional workforce, Develop staff as an effective force for community health, Serve as an advocate in the community to increase healthy choices available to the population, Use economic leverage within the community for health-related changes, The Future of the Public's Health in the 21st Century. These diseases include immune deficiency (e.g., HIV/ AIDS), viral diseases (e.g., herpes and mumps), cancer and leukemia, diabetes, heart disease, kidney disease, anemia, hemophilia and other bleeding disorders, adrenal gland disorders, and inflammatory bowel disease (Bajuscak, 1999; Glick, 1999). Some provide no personal health care services at all, whereas others provide some assortment of primary health care and safety-net services. The committee views these status and resource differences as barriers to mutually respectful collaboration and to achieving the shared vision of healthy people in healthy communities. 2001. CMS (2002a); CMS (2002a); CMS (2002c). 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. 5, The Health Care Delivery System. Assuring the health of the population in the twenty-first century requires finding a means to guarantee insurance coverage for every person living in this country. 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. National Academies Press (US), Washington (DC). 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. Fragmentation of health plans along socioeconomic lines engenders different clinical cultures, with different practice norms (Bloche, 2001). Additionally, disabling chronic conditions affect all age groups, but about two-thirds are found in individuals over age 65. Objective The WHO developed a manual outlining the preliminary organizational and health professionals' readiness to implement electronic medical records (EMR). 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. 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.. Burn care beds and other special care beds intended for care that is less intensive than that provided in an ICU and more intensive than that provided in an acute care area. 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. 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. Although these various individuals and organizations are generally referred to collectively as "the health care delivery system," the phrase suggests an order, integration, and accountability that do not exist. Each element is equally important in providing high-quality care to our patients in the 11 countries where . An estimated 100 million Americans have one or more chronic conditions, and that number is estimated to reach 134 million by 2020 (Pew Environmental Health Commission, 2001). 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). This may be because of cost concerns or insurance plan restrictions or simply professional judgment that the test is unnecessary for appropriate clinical care. That report emphasized that untreated health problems can affect children's physical and emotional growth, development, and overall health and well-being. 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. (2002); CMS (2002a); CMS (2002c). Protection against specific illnesses. 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. By almost any metric, uninsured adults suffer worse health status and live shorter lives than insured adults (IOM, 2002a). Implement multidisciplinary treatment and preventive care teams. AAMC (Association of American Medical Colleges). Journal of Mental Health Policy and Economics, Trends in mental health services use and spending, 19871996, Recommendations Concerning Safety-Net Services, Partnership for Prevention Survey of Employer Support for Preventive Services, Children's Preventive Health Care under Medicaid, Distribution (percent) of Sources of Payment for Mental Health/Substance Abuse Treatment, by Type of Use, 1996, Oral Health as a Component of Total Health, Legal, Regulatory, and Policy Interventions to Eliminate Racial and Ethnic Disparities in Health Care, www.hospitalconnect.com/ aha/awards-events/awards/novaaward.html, http://cms.hhs.gov/researchers/pubs/ CMSStatistics BlueBook2002.pdf, http:// info.ihs.gov/Infrastructure/Infrastructure6.pdf, www.rwjf.org/ app/rw_grant_results_reports/rw_grr/029975s.htm, www.kff.org/ content/archive/1450/private_s.pdf, www.montefiore. 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. 2002. Components of the U.S. health care system. 1998. 2000. 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. 1999. The total social costs of alcohol abuse alone were estimated at $177.3 billion in 1997 (Coffey et al., 2001). 2001. However, the committee finds that both the scale of the problem and the strong evidence of adverse health effects from being uninsured or underinsured make a compelling case that the health of the American people as a whole is compromised by the absence of insurance coverage for so many. Health insurance coverage is associated with better health outcomes for adults. Use of the word "delivery" is deprecated by critics who . 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). The issues are complex, and the failures of health care reform efforts over the past 30 years testify to the difficulty of crafting a solution. 2002. Services, Consumers, Personnel, and Payment Hospitals vary in size, ownership, and types of services. The participant ratethe number of children screened compared to the number of children expected to be screened, based on the federal periodicity schedule and the average period of eligibilityincreased from 51 percent in 1994 to 56 percent in 1996. For children, too, being uninsured tends to reduce access to health care and is associated with poorer health. Crossing the Quality Chasm (IOM, 2001b) examined health system failures that compromise the quality of care provided to all Americans. Medical professionals such as WHO agree that embracing the 6 components of health will allow patients to lead more complete lives. CDC (Centers for Disease Control and Prevention). Jones R, McConville J, Mason D, Macpherson L, Naven L, McEwen J. Implement patient education programs to increase patients' knowledge of how to best access care and participate in treatment decisions. Committee on Medicine and Public Health. 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). The committee recommends that bold, large-scale demonstrations be funded by the federal government and other major investors in health care to test radical new approaches to increase the efficiency and effectiveness of health care financing and delivery systems. 2001. The third component is primary care. Explore Topics: 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). For the patient, the model provides comprehensive care, an emphasis on prevention, and low out-of-pocket costs. 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). Reinhardt UE, Hussey PS, Anderson GF. Prevention and well care. The considerably smaller, less well-appreciated public health sector concentrated on populations, prevention, nonbiological determinants of health, and safety-net primary care (Lasker et al., 1997: 274). The committee cautions, however, that systems dedicated to a single use, such as bioterrorism, will not be optimal; systems designed to be comprehensive and flexible will be of greater overall value. In addition, uninsured patients are making greater use of emergency departments for nonurgent care. The facts about uninsurance in America are sobering (see Box 51). This could significantly undermine the current pooling of risk and create incentives for overuse of high-technology services once a deductible for catastrophic benefits has been met. During the 1990s, Medicaid shifted from a fee-for-service program to a managed care model. Surveys conducted over the past two decades show a consistent underestimation of the number of uninsured and of trends in insurance coverage over time (Blendon et al., 2001). 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).