Mental health parity: what are the gaps in coverage? 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. An aging workforce may have implications for patient care if older RNs have less ability to perform certain physical tasks (HRSA, 2001). Although this committee was not constituted to investigate or make recommendations regarding the serious economic and structural problems confronting the health care system in the United States, it concluded that it must examine certain issues having serious implications for the public health system's effectiveness in promoting the nation's health. The demonstrations should be supported by adequate resources to enable innovative ideas to be fairly tested. The 2000 National Sample Survey of Registered Nurses reported that 5 percent of RNs are African American, 2 percent are Hispanic, and 3.5 percent are Asian (Spratley et al., 2000). Health Research and Educational Trust (HRET). CMS Publication 03437. 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. Medical screening. 2002. The adequacy of hospital capacity cannot be assessed without considering the system inefficiencies that characterize current insurance and care delivery arrangements. These components do fit into a systems model, despite all its limitations. For most Americans, having health insurance under a private plan or through a publicly financed programis a threshold requirement for routine access to health care. tailored to your instructions. Being uninsured, although not the only barrier to obtaining health care, is by all indications the most significant one. Public sources provide more than two-thirds of the funding for alcohol and drug treatment facilities. 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 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. In addition to the linkages between the health care delivery system and governmental public health agencies, health care providers also interface with other actors in the public health system, such as communities, the media, and businesses and employers. For example, toxic or infectious exposures could be tracked more easily if the characteristics of every patient encounter were integrated into one system and if everyone had unimpeded access to systems of care that could generate such data. All federal programs and policies targeted to support the safety net and the populations it serves should be reviewed for their effectiveness in meeting the needs of the uninsured. 2002. Enhanced information technology also promises to aid patients and the public in other ways. Inpatient care including emergency care, labor and delivery, intensive care, diagnostic imaging Cooper-Patrick L, Gallo JJ, Powe NR, Steinwachs DM, Eaton WW, Ford DE. In that same year, $6.4 billion was spent on treatment. CMS (2002a); CMS (2002a); CMS (2002c). Contrary to popular belief, recent immigrants accounted for a relatively small proportion of the uninsured (less than one in five). (Eds.). The Population Health Care Delivery Model. 2. The Future of the Public's Health in the 21st Century. These trends do not appear to be a temporary, cyclical phenomenon. Access to health care consists of four components ( Healthy People 2020 ): Coverage: facilitates entry into the health care system. Other changes in the health care delivery system also raise concerns about the infectious disease surveillance system. To outline the four key functional components of a health care de-livery system To discuss the primary characteristics of the US health care system from a free market perspective To emphasize why it is important for health care managers to under-stand the intricacies of the health care delivery system To get an overview of the . Looking at 12 communities, Brewster and colleagues (2001) found that on average in 2001, two hospitals in Boston closed their emergency departments each day and the Cleveland Clinic emergency departments were closed to patients arriving by ambulance for an average of nearly 12 hours a day. Although cardiovascular disease is the leading cause of death and diabetes is one of the most significant chronic diseases affecting Medicare beneficiaries, physicians cannot screen for lipids disorders or diabetes unless the patient agrees to pay out-of-pocket for the tests. Medical professionals such as WHO agree that embracing the 6 components of health will allow patients to lead more complete lives. Good primary care assures continuity for the patient across levels of care, comprehensiveness of services according to the level of health or illness, and better coordination of these services over time (Starfield, 1998). The overcrowding was severe, resulting in delays in testing and treatment that compromised patient outcomes. For unusual or particularly serious conditions, public health officials offer guidance on treatment options and control measures and monitor the community for any additional reports of similar illness. In addition, uninsured patients are making greater use of emergency departments for nonurgent care. 11. 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). More than 90 percent of systemic diseases have oral manifestations. 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. The total social costs of alcohol abuse alone were estimated at $177.3 billion in 1997 (Coffey et al., 2001). Such arrangements have made possible some level of integration of health care and public health services, enhanced information exchange and continuity of care, and allowed public health departments to be reimbursed for the provision of some of the services that are covered by the benefits packages of managed care plans (Martinez and Closter, 1998). of those objectives, a healthcare delivery system concept model was developed (see Figure 3) that is comprised of three major components: primary . 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. The number of eligible children fell by more than half a million between 1995 and 1996. Additionally, disabling chronic conditions affect all age groups, but about two-thirds are found in individuals over age 65. 1996. Pew Environmental Health Commission. What are some delivery systems? Recent studies have shown impressive results for treatment of depression in primary care settings (Sturm and Wells, 2000; Schoenbaum et al., 2001). 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). Hospitals are in better compliance with the federal Emergency Medical Treatment and Labor Act, which requires emergency departments to treat patients without regard for their ability to pay. The EIP sites have performed investigations of meningococcal and streptococcal diseases and have established surveillance for unexplained deaths and severe illnesses as an attempt to identify diseases and infectious agents, known and unknown, that can lead to severe illness or death (CDC, 2002). Although this survey serves only as an illustration of what may be possible, several elements appeared supportive of a sustained commitment to efforts at community health improvement. In addition to these services, some people consult traditional health care providers. 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. Cost-sharing requirements for these services may also be higher than those for other commonly covered services. In particular, managed care rules have changed to allow increased coverage of care provided in emergency departments. Mexican-American adults and children are more likely to have untreated decayed teeth than any other population group. However, such plans have yet to assume a significant role in the insurance market, and few employers offer them as an alternative. Solanki G, Schauffler HH, Miller LS. A survey of 69 hospitals belonging to the National Association of Public Hospitals indicated that in 1997, public hospitals provided more than 23 percent of the nation's uncompensated hospital care (measured as the sum of bad debt and charity care) (IOM, 2000a). In general, hospitals in rural areas report the highest percentage of vacant positions. 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). First, managed care plans reimburse safety-net providers less generously than fee-for-service Medicaid providers do (under Medicaid, federally qualified health centers benefited from a federal requirement for full-cost reimbursement), and they impose administrative and service restrictions that result in reduced overall rates of compensation (IOM, 2000a). (Eds.). Bates D, Cohen M, Leape LL, Overhage JM, Shabot MM, Seridan T. 2001. However, the high out-of-pocket costs faced by individuals who pay for their own treatment discourage many who need care from seeking it. The pattern for adults is similar (DHHS, 2000b: 6364). Disease reporting is not complete, however. Preventive Services Covered by Medicare. The health care delivery system as it exists today cannot deliver those elements. While there 2001. Reimbursement rate reductions, restrictions on care and choice of physician, and other aspects of plan management disaffected millions of Americans from the basic concept of managed care. The committee found that preventive, oral health, mental health, and substance abuse treatment services must be considered part of the comprehensive spectrum of care necessary to help assure maximum health. However, when fewer diagnostic tests are performed for self-limiting illnesses like diarrhea, there may be delays in recognizing a disease outbreak. However, payment systems are critical to encourage and sustain these network initiatives, and current reimbursement policies in public and private insurance are not designed to support population-focused care in a noncapitated system. Furthermore, when the delivery of health care through the private sector falters, the responsibility for providing some level of basic health care services to the poor and other special populations falls to governmental public health agencies as one of their essential public health services, as discussed in Chapter 1. Coverage of clinical preventive services has increased steadily over the past decade. In 1996, 22.9 million children (20 percent of the nation's children) were eligible for EPSDT benefits. Channeling purchasing power into community business, Housing development through capital leverage, Minority Graduates of US Medical Schools: Trends, 19501998, Emergency departmentsan essential access point to care, The health care workforce shortage and its implication for America's hospitals, Depression in Primary Care: Treatment of Major Depression, Nurses' report on hospital care in five countries, Lower Medicare mortality among a set of hospitals known for good nursing care, Dental insurance is essential, but not enough, Socioeconomic characteristics of medical practice 1997/ 98, Emergency departments and crowding in United States teaching hospitals, Unmet health needs of uninsured adults in the United States, Journal of the American Medical Association, Health insurance and access to care for symptomatic conditions, Beyond the Medical Model: Hospitals Improve Community Building, Community Care Network (CCN) Briefings, Fall 2001, Reducing the frequency of errors in medicine using information technology, Journal of the American Medical Informatics Association, Effect of computerized physician order entry and a team intervention on prevention of serious medication errors, The status of local health care safety-nets, Assessing Core Capacity for Infectious Diseases Surveillance, Final Report prepared for the Office of the Assistant Secretary for Planning and Evaluation. 2001. Taken in the aggregate, these funding streams are neither adequate nor reliable enough to meet the needs of individuals with serious mental disorders (IOM, 2000a). When offered, coverage for these services often carries limits that are unrelated to treatment needs and are stricter than those for other types of care (King, 2000). 1999. Delivery. Each of the 6 components of health is somehow integrated, which incorporates social, physical, emotional, spiritual, cognitive, and cultural health. 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. Figure 1-1 illustrates that a health care delivery system incorporates four functional componentsfinancing, insurance, delivery, and payment, or the quad-function model. 1999. Objective The WHO developed a manual outlining the preliminary organizational and health professionals' readiness to implement electronic medical records (EMR). The healthcare delivery system is combination of four major components including finance, insurance, delivery, and payment which makes the healthcare delivery system most unique and qualitative in terms of providing healthcare unlike any other country in the world. Integrated Delivery System. 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. In considering the role of the health care sector in assuring the nation's health, the committee took as its starting point one of the recommendations of the Institute of Medicine (IOM) report Crossing the Quality Chasm (2001b: 6): All health care organizations, professional groups, and private and public purchasers should adopt as their explicit purpose to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States.. Unlike forms of treatment that are incorporated into the payment system on a relatively routine basis as they come into general use, preventive services are subject to a greater degree of scrutiny and a demand for a higher level of effectiveness, and there is no routine process for making such assessments. The difficulty of reporting in a busy practice is also a barrier. 2000. False Reduced use of laboratory testing prevents the analyses of pathogenic isolates needed for disease tracking, testing of new pathogens, and determining the levels of susceptibility to antimicrobial agents. However, even when the uninsured receive care, they fare less well than the insured. 2001. Immunization rates have improved from 36 to 99 percent, and teen pregnancy is down to 31 per 1,000 from 44 per 1,000. A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020, Local Public Health Agency Infrastructure: A Chartbook, Medicaid and Other Health Care Issues. 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. . For individuals with Medicare, the following services are covered by Medicare Part B: Number of eligible children. Denver Health is the local (county and city) public health authority, as well as a managed care organization and hospital service. The severe underrepresentation of racial and ethnic minorities in the health professions affects access to care for minority populations, the quality of care they receive, and the level of confidence that minority patients have in the health care system. Wagner and colleagues (1996) identified five elements required to improve outcomes for chronically ill patients: Reorganization of practices to meet the needs of patients who require more time, a broad array of resources, and closer follow-up. Although the terrorist incidents in the fall of 2001 did not directly test the ability of hospitals to respond to a medical crisis, they drew particular attention to hospitals' limited surge capacitythe ability to absorb a large influx of severely injured patientsin their emergency departments and specialty units. Rabinowitz J, Bromet EJ, Lavelle J, Hornak KJ, Rosen B. NASBO (National Association of State Budget Officials). 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. However, the increase in health spending also reflects the success of federal and state efforts to enroll more low-income children in Medicaid and the State Children's Health Insurance Program, increased enrollment in Medicare as the population ages, and some erosion of unpopular cost-control features imposed by managed care plans. See also pregnancy. (Ed.). For example, the California Public Employees' Retirement System, which is the nation's second largest public purchaser of employee health benefits, recently announced that health insurance premiums would increase by 25 percent (Connoly, 2002). Scientific and technological advances will permit clinical care to intervene early in a disease process by identifying and modifying personal risk. 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. It is also associated with having a regular source of care and with greater and more appropriate use of health services. The latter rely on health care providers and laboratories to supply the data that are the basis for disease surveillance. Furthermore, changes in the funding streams or reimbursement policies for any of these programs or increases in demand for free or subsidized care that inevitably occur in periods of economic downturn create crises for safety-net providers, including those operated by state and local governments (see the section Collaboration with Governmental Public Health Agencies later in this chapter for additional discussion). The committee took special note of certain shortages of health care professionals, because these shortages are having a significant adverse effect on the quality of health care. For individuals with Medicare, the following services are covered by Medicare Part B: Bone mass measurements for people at risk of losing bone mass. 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. 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). 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). Typically subspecialty care focused on a particular organ system or disease process. The four function- al components make up the quad-function model. Unfortunately, data on the program's progress are incomplete and inconsistent across the country, despite federal requirements for state reports (GAO, 2001a). DHHS (2002). The operational separation of public health and health care financing programs mirrors the cultural differences that characterize medicine and public health. for only $13.00 $11.05/page. In this section, the committee reviews concerns about the barriers to health care that are raised by the lack of health insurance and by threats to the nation's safety-net providers. 1.1.1. Using delivery system innovations to advance health care reform continues to be of widespread interest. Here, we'll discuss seven common models: HMO, PPO, POS, EPO, PFFS, SNP and ACO and examine the differences between each one. Between 1991 and 1996, the number of children eligible for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program increased by roughly 5.7 million, with the highest number (23.5 million children) occurring in 1995. For the most prevalent mental health disorders such as depression and anxiety, receipt of appropriate care is associated with improved functional outcomes at 2 years (Sturm et al., 1995), but the majority of individuals suffering from mental illness are not treated for their condition (DHHS, 1999). Children without health insurance may be compromised in ways that will diminish their health and productivity throughout their lives. Total of medical and surgical beds, ICU beds, and special care beds. As detailed in Crossing the Quality Chasm (IOM, 2001b: 27), effective health care for chronic disease management is a collaborative process, involving the definition of clinical problems in terms that both patients and providers understand; joint development of a care plan with goals, targets, and implementation strategies; provision of self-management training and support services; and active, sustained follow-up using visits, telephone calls, e-mail, and Web-based monitoring and decision support systems.. A recent study of changes in the capacities and roles of local health departments as safety-net providers found, however, that more than a quarter of the health departments surveyed were the sole safety-net providers in their jurisdictions and that this was more likely to be the case in smaller jurisdictions (Keane et al., 2001). These providers include institutions and professionals that by mandate or mission deliver a large amount of care to uninsured and other vulnerable populations. Focuses on quality of care, not volume of services provided Aligns incentives across all parts of our system, with patients at the center, delivering high-value care and keeping costs reasonable Invests in new technologies and innovations to advance quality of care The U.S. Preventive Services Task Force calls these interventions vitally important..
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