Running Head: Historical and Current Trends in Health Care that have Led to the Demands for Change Important Historical and Current Trends in U.S. Health Care that have Led to the Demands for Change Ardavan A. Shahroodi Northeastern University Professor James J. Ferriter HMG-6110- The Organization, Administration, Financing and History of Health Care in the U.S. Final Term Paper Thursday, May 16, 2013
Transcript
1. RunningHead: Historical andCurrentTrends in HealthCare that
have Ledto the DemandsforChange Important Historical and Current
Trends in U.S. Health Care that have Led to the Demands for Change
Ardavan A. Shahroodi Northeastern University Professor James J.
Ferriter HMG-6110- The Organization, Administration, Financing and
History of Health Care in the U.S. Final Term Paper Thursday, May
16, 2013
2. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change Introduction Our system of health care is
facing a number of crucial decisions in the coming years. An era of
ever increasing cost over runs in the health care environment has
placed unsustainable financial pressures on our economy and public
treasuries. In spite of these uncontrollable expenditures, the
quality of the health care products and services suffer from
inconsistencies and lack of uniformity in effectiveness and
implementation. In addition, until very recently a sizable minority
of the population did not enjoy the protection of any health care
insurance coverage. The reforms of the Affordable Care Act (ACA)
aim to rectify some of the most intractable problems in the care
system such as the lack of health insurance for so many Americans.
ACA will also create a number of initiatives, organizations and
financial incentives that will contribute towards improving quality
and controlling the cost escalation associated with delivering
health care in this country. Unsustainable Cost Structure in the
Present and the Specter of Ever Increasing Cost Escalation on the
Horizon In a historical analysis of the health care expenditures in
the U.S., Barr (2011) brings attention to the fact that in 1970,
people in the United States spent a total of $73 billion, or an
average of $ 341 per person per year, on all types of health care
combined (p. 19). At the time, this amount represented 7.1 percent
of the gross domestic product (GDP) of the country (Barr, 2011, p.
19). Sisko et al. (2010) estimate that total health care
expenditures in 2009 had escalated to $2.5 trillion that was 17.3
percent of the GDP and the average per person cost had risen to
$8,200 on a yearly basis (as cited by Barr, 2011, p. 19). Truffer
et al. (2010) project that by 2019; health care costs will have
risen to 19.3 percent of the GDP (as cited by Barr, 2011, p.
19).
3. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change With respect to the cost of the Medicare
Insurance program that covers those over 65 years old and
represents a significant portion of health care expenditures in
this country, Barr (2011) informs us that the price of this
particular entitlement had risen from $4.2 billion in 1967 to $9.3
billion in 1973 (p. 140). Barr (2011) adds that in 2009Medicare
expenditures for Part A + Part B totaled $448 billion (p. 140) and
by 2010, the cost of all Medicare programs combined was $504
billion. As a result, presently, the cost for Medicare programs
comprise approximately 1 in every 5 dollars spent on health care,
in light of the above figure for total national expenditures of
$2.5 trillion dollars on a yearly basis. The Kaiser Family
Foundation (2013) has estimated that Medicare spending is projected
to grow from $551 billion to $1 trillion in 2022 (Medicare at a
Glance, Nov 14, 2012). Some important additional statistics here
are that when Medicare was introduced in the U.S. during the 1960s,
approximately 9.5 percent of the countrys population was 65 years
or older (Barr, 2011, p. 143). However, by 2010, this number of
persons over 65 years old had risen to 13 percent of the population
(Barr, 2011, p. 143). Furthermore, Barr (2011) states that current
projections predict that the proportion of the population 65 or
over will rise to 16.1 percent by 2020 and 19.3 percent by 2030 (p.
143). Kaiser Family Foundation (2010) has estimated that in 2006,
Medicare spent an average of 8,344 per elderly beneficiary (not
including the cost of prescription drug coverage (as cited in Barr,
2011, p. 143). This is a very interesting number since Kaiser
Family Foundation (2010) also tells us that the sickest 10 percent
of beneficiaries had an average annual per capita cost of $48,210,
and accounted for nearly 60 percent of all spending (as cited in
Barr, 2011, p. 143). On the other hand, Kaiser Family Foundation
(2010) informs us that in 2006 almost 34 percent
4. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change of the beneficiaries in the Medicare program
spent in between zero to one percent of the total expenditures (as
cited in Barr, 2010, p. 143). Kaiser Family Foundation (Medicare at
a Glance, Nov 14, 2012), has estimated that from 2000 to 2012,
Medicare and private health insurance per capita spending has
experienced an average annual growth rate of 6.9 percent, while per
capita GDP has increased by 2.9 percent and the Consumer Price
Index (CPI) has increased by 2.5 percent. Kaiser Family Foundation
(Medicare at a Glance, Nov 14, 2012) projects that from 2012 to
2021, Medicare and private health insurance will increase an
average annual growth rate of 3.6 and 5 percent respectively, while
per capita GDP will be enhanced by 4 percent and the Consumer Price
Index will increase by 2.1 percent. In spite of the aforementioned
costs estimates and projections, it is most important to keep in
mind that the Medicare system, despite being one of the largest
government programs in history, has proven to be one of the most
efficient administrative systems for providing health care to a
defined population of patients (Barr, 2011, p. 161). When we take
the percentage insurance programs spend on administrative expenses,
we observe that these costs for Medicare Parts A and B vary between
1 to 2.5 percent, while employer-based insurance programs
experience non-patient care costs that run anywhere from 10 to 30
percent and nonprofit HMOs experience non-patient care costs of 3
to 7 percent (Barr, 2011, p. 161). The conclusion that we may draw
from the above figures is that cost escalation in the case of
Medicare is unrelated to matters of administrative efficiency. In
regards to the Medicaid program, Kaiser Family Foundation (The
Medicaid Program at a Glance, March 04, 2013) estimates that in FY
2011 total Medicaid spending excluding administration (5%, data not
shown) totaled $414 billion. Kaiser Family Foundation (The
5. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change Medicaid Program at a Glance, March 04, 2013)
does bring to our attention that two-thirds of Medicaid spending
was attributable to acute care and one-third went toward long-term
care while roughly two-thirds of Medicaid spending is attributable
to elderly disabled beneficiaries. Here, Barr (2011) adds that
Sixty-seven percent of Medicaid costs go to provide care for 25
percent of beneficiaries (p. 173). As much as low income children
and adults comprise 75 percent of Medicaid beneficiaries, only 32
percent of spending is attributable to these population groups
(Barr, 2011, p. 173). The Office of the Actuary (OACT) in the
centers for Medicaid and Medicare Services (CMS) (March 2012) has
projected that Medicaid expenditures are to increase at an average
annual rate of 6.4 percent over the next 10 years, and to reach
$795.0 billion by 2021 (total outlays not just federal) (as cited
in Kaiser Commission on Medicaid and the Uninsured Issue Paper,
March 2013). The rising expenditure on prescription drugs is
another factor contributing to the escalating health care cost
structure in the U.S. Prescription drug expenditures in 1980, U.S.
Centers for Medicare and Medicaid Services (data from website)
inform us, totaled 4.9 percent of all heath care costs (as cited in
Barr, 2011, p. 215). In 1990, those costs had risen to 5.8 percent
and by 2003 the expenditures had a 10.7 percent of the national
health care costs (Barr, 2011, p. 215). Barr informs us that
between 1993 and 2003, while national health expenditures increased
89 percent, expenditures for prescription drugs increased 249
percent (Barr, 2011, p. 215). Nevertheless, Barr (2011) relays to
us that the cost of prescription drugs is projected to remain at
approximately 10 percent of national health expenditures through
2019 (p. 215). A Kaiser Family Foundation (2004) study of the
period 1997-2002, attributed the increase in expenditures of
prescription drugs to the increases in the number of prescriptions
issued/44 percent (as cited in Barr, 2011, p. 216), manufacturers
price increases for existing drugs/25
6. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change percent (Ibid) and shifting from a less
expensive drug to a more expensive drug for the same illness/34
percent (Ibid). Barr (2011) points towards a number of factors in
the U.S. that are causing and will cause in the future for the cost
of health care to increase. First, an expanding population and as
suggested in the preceding sections an ever larger population of
elderly Americans enhance health care expenditures. Second, the
number of people receiving treatment for a specific illness may go
up (Barr, 2011, p. 22) due to the pattern that either the illness
is becoming more common, or more people with the condition may seek
treatment (Ibid). These illnesses or treatments could be diabetes,
cardio vascular disease, mental illness, orthopedic surgery or
other maladies and therapeutic solutions. Third, the expense of
treating an illness may increase based on new, more advanced (and
more high-tech) treatments becoming available, replacing older,
less expensive (and more low-tech) treatments (Barr, 2011, p. 22).
Barr (2011) also argues that in the U.S., technology and
technological advances (p. 56) occupy a special place in our
national purpose and psyche and as a result advances in medical
technology are highly valued, even when the added benefit of these
treatments is small compared to their cost (p. 56). Fuchs (1983)
refers to this tendency as the technological imperative (as cited
in Barr, 2011, p. 57) where both physicians and patients understand
quality in terms of the aggressive usage of more advanced
technologies in the treatment of disease. This inclination to
equate technology with quality (Barr, 2011, p. 57) has brought us
to a belief system that asserts the more technological a treatment
is, the better it is (Ibid) and that as patients we have not
received complete treatment unless we receive the most advanced
technology (Ibid).
7. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change Barr (2011) uses a number of examples to
illustrate the above phenomenon such as the practice of ordering
MRIs for an overwhelming number of orthopedic related conditions
regardless of the severity of the patients injuries (p. 56). The
same situation is prevalent with the usage of the relatively
expensive (Barr, 2011, p. 57) prostate specific antigen (PSA) blood
test that possesses a high risk of false-positive results (Ibid).
In addition, there is also the case of medications for controlling
blood pressure where ALLHAT Collaborative Research Group (2002)
found that the standard treatment of diuretics are superior in
preventing one or more major forms of cardiovascular disease and
are less expensive. They should be preferred for first- step
anti-hypertensive therapy (as cited in Barr, 2011, p. 59).
Nevertheless, other more expensive and technologically advanced
medications are still being widely used in spite of the scientific
evidence to the contrary regarding their superiority to diuretics
in treating high blood pressure. Barr (2011) also introduces the
opinions of Hillman and Goldsmith (2010) in describing the roots of
health care cost escalation in the U.S. Hillman and Goldsmith
(2010) argue that there has been an imaging boom in U.S. health
care although an unknown but substantial fraction of imaging
examinations are unnecessary and do not positively contribute to
patient carethe evidence basis for using imaging is incomplete (as
cited in Barr, 2011, p. 64). In a similar observation, Leff and
Finucane (2008) describe this all-consuming prevalence of high-
tech imaging and other devices as gizmo idolatry (as cited in Barr,
2011, p. 64) based on the belief that a more technological approach
is intrinsically better than one that is less technological unless,
or perhaps even if, there is strong evidence to the contrary
(Ibid). Barr (2011) contends the prevailing inclination of
physicians in this country to practice defensive medicine (p. 65)
based on concerns for malpractice lawsuits has added billions of
dollars to
8. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change our health care budget by ordering extra
tests and procedures that add little to care but present a stronger
defense (Ibid) in the event of patient oriented litigation. The
Inability of Managed Care and Managed Competition to Mitigate Cost
Escalation and Improve Quality The concept of managed care health
plans or health maintenance organizations (HMOs) was first
introduced by organizations such as the respectable Kaiser
Permanente system in the state of California. These non-profit
operations were also labeled as prepaid group practice (Barr, 2011,
p. 106) who charged a fixed monthly fee (Ibid) or capitation rate
(Ibid) and in exchange provided for their members hospital care,
physician care and other outpatient services (p. 107). In the
beginning, these health care plans were consistently able to
provide comprehensive care at a substantially lower cost than the
insurance plans using the traditional fee-for-service method of
paying for care (Barr, 2011, p. 107). A study by Manning et al.
(1984) at the Rand Corporation found that given comparable patient
populations, prepaid group practice service plans could be as much
as one-third less expensive than fee-for-service insurance plans
for comparable care (as cited by Barr, 2011, p. 107). Nevertheless,
a further study by Davies et al. (1986) pointed towards lower
patient satisfaction in a number of aspects of the primary care
process (as cited in Barr, 2011, p. 108) with respect to the HMO
operations. A third large study, called the Medical Outcome Study
by Safran, Tarlov and Rogers (1994) spanning a period of four years
and involving 1208 patients with chronic diseases also found that
group HMO had a lower cost of care and better communication among
specialists and primary care physicians (as cited in Barr, 2011, p.
113). However, in this study, HMOs had lower ratings than other
care arrangements (fee-for-service) in access to care, continuity
of care, and comprehensiveness of care (Barr, 2011, p. 113). In
all
9. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change these and other studies, HMOs projected lower
patient satisfaction (Barr, 2011, p. 114) ratings versus
traditional fee-for-service practitioners (Ibid). The success of
HMOs in controlling costs led some reformers such as Enthoven
(1980) to propose the creation of a national system of health care
centered on the concept of groups of health care purchasers banding
together to obtain health insurance from competing health insurers
(as cited in Barr, 2011, p. 116). Enthoven (1980) proposed a system
of fair economic competition in which customers and providers of
care, making decisions in an appropriately structured private
market (as cited in Barr, 2011, p. 116) would replace a system of
health care based on built-in cost-increasing incentives (Ibid)
with one structured on built- in incentives for customer
satisfaction and cost control (Ibid). However, Barr (2011) reminds
us that the inherent inefficiencies in our system of health care
such as the non-taxable nature of health insurance premiums and the
system of paying physicians a separate fee for each service
provided regardless of the added benefit of that service (p. 119)
has created an environment with patients expecting and physicians
providing a great deal of expensive care with relatively little
marginal benefit (Ibid). Nevertheless, Enthoven (1980) did propose
the creation of a system of health care where on a regional
basispatients choose between competing systems of managed care
(Managed Competition) (as cited in Barr, 2011, p. 118). However, as
North (1986) would argue and Barr (2011) paraphrases many types of
institutional force inhibit the ability of markets to achieve
efficiency (as cited in Barr, 2011, p. 124) such as the
technological imperative (Ibid) discussed in the preceding
paragraphs. In addition, the concept of managed competition has
remained largely theoretical with many small and medium size firms
offering only one or two managed care plans to their employees. The
Kaiser Family Foundation and Health Research and Educational Trust
reported that in 2009,
10. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change almost 80 percent of employees nationally had
the choice of access to only one or two health plans (as cited in
Barr, 2011, p. 127). Where, managed care operations did endeavor to
control costs they utilized strategies that was meant to reduce the
use of care, and through a reduction in the amount they would pay
physicians and hospitals for care (Barr, 2011, p. 128). Both these
strategies created the managed care backlash (Barr, 2011, p. 128)
that led the purchasers of insurance to accept the reality of
increasing health care costs (Ibid). The aforementioned measures
that some managed care organizations (mostly for-profit) utilized
in order to control expenses included the usage of primary care
physicians (PCPs) as gatekeepers for other care the patient might
need (Barr, 2011, p. 194). The usage of the PCPs as gatekeepers
proved on occasion to be a controversial practice when physicians
received a fixed amount of money to provide all out-patient care
and tests for each patient in his or her practice for a given
period of time and this total amount would also include their
salary. Consequently, the PCPs would continuously have to face the
predicament of potential conflict of interest scenarios that placed
them in an untenable decision making quandary. As Barr (2011) would
argue, linking the gatekeeper function directly to the physicians
income created an obvious ethical conflict (p. 195). A further
practice of managed care organizations that proved to be
problematic was the usage of the utilization review department
(Barr, 2011, p. 195) that monitored and reviewed the care provided
by physicians (Ibid). The utilization review department would have
to grant prior approval in order for physicians to be able to order
expensive tests such as MRIs or admit their patients to hospitals.
In addition, the utilization review departments would also monitor
the patients while they were in the hospital so that physicians do
not keep them in those environments for too long (Barr, 2011, p.
195).
11. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change In many instances, managed care organizations
gathered statistics on how often each physician used expensive
resources such as MRIs, drugs, hospitals, operations and the like
(Barr, 2011, p. 195). Managed care organizations would then
penalized physicians whose profile exceeded what the reviewers
thought was appropriate (Barr, 2011, p. 195) with the usage of
these physician practice profiles (Ibid). On the other hand, a
number of managed care operations followed the practice of
rewarding physicians that had kept down costs during the year
(Barr, 2011, p. 196) by directly linking a physicians bonus to the
cost of the care that the physician had ordered during the year
(Ibid). The aforementioned annunciated procedures of evaluating a
physicians performance primarily on the basis of her or his
financial decision making was not replicated in all managed care
operations. Some managed care operations have developed structured
programs of education and feedback to remind physicians which type
of care are most appropriate and which type may be inappropriate
(Barr, 2011, p. 196). In addition, highly respected non-profit
managed care organizations such as the Kaiser Permanente system
have never utilized a direct bonus system and the physicians have
always received an indirect bonus. In the event that the cost of
care was less than the amount budgeted, the surplus was not added
to the bonus pool but rather was invested in the Kaiser Permanente
system (Barr, 2011, p. 198). Furthermore, the Kaiser Permanente
system places a heavy emphasis on physician education and feedback,
and on gatekeeper systems that were not linked to physician
compensation (Barr, 2011, p. 198). In spite of the credibility that
organizations such as the Kaiser Permanente system bring to the
managed care environment, Arnold Relman (2007), a former editor of
the authoritative New England Journal of Medicine has stated that
the entry and growth of innumerable private investor-owned
businesses that sell health insurance and deliver medical care with
a primary
12. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change concern for the maximization of their income
(as cited in Barr, 2011, p. 211) has dominated the delivery of
health care. In a most troubling statement that may possess
profound consequences for all of us, Relman (2007) argues that, the
continued privatization of health care and the continued prevalence
and intrusion of market forces in the practice of medicine will not
only bankrupt the health care system, but also inevitably undermine
the ethical foundations of medical practice and dissolve the moral
precepts that have historically defined the medical practice (as
cited in Barr, 2011, p. 211). Gawande (June 1, 2009) argues that in
certain communities physicians who see their practice primarily as
a revenue stream and view their patients as profit centers have
come to predominate the health care profession. In citing the
research of Woody Powell (a Stanford sociologist) regarding the
anchor-tenant theory of economic development, Gawande (June 1,
2009) observes that in these health care communities the
aforementioned anchors/practitioners set the norms for medical
practice. However, on the other end of the spectrum, world class
and highly effective health care organizations such as the Mayo
clinic promote leaders who focused first on what was best for
patients, and then on how to make this financially possible
(Gawande, June 1, 2009). In the Mayo Clinic, Gawande (June 1, 2009)
observes The needs of the patient come first-not the convenience of
the doctors, not their revenues and in this mission the entire work
force sill have weekly meetings in order to make the service and
the care better. In addition, in the Mayo Clinic, all the employees
including the physicians receive a salary so that the doctors goal
in patient care couldnt be increasing their income (Gawande, June
1, 2009). One of the central challenges of our health care system
is how to evolve form a process oriented and transaction based
structure susceptible to the abuses, cost overruns and
inefficiencies
13. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change annunciated in the Gawande (June 1, 2009)
article to a system replicating the standards of an organization
such as the Mayo Clinic that are outcome oriented, accountable,
quality laden, patient centered and effective. As Professor
Ferriter (Class 6, Lecture Outline, P. 4) has stated such a system
will also be cognizant of the fact that profit in and of itself is
not inherently bad, but should not drive the decision to deliver
the best care in a competitive market. The Problem of the Uninsured
and other Barriers that Compromise Access to Health Care Barr
(2011) informs us that in 2009, approximately 16.7 percent of
Americans-50.7 million people-faced the prospect of illness or
injury with no health insurance (p. 253). This number of people
without coverage does not include those who were without insurance
for some period of time during the year but were not uninsured for
the entire year (Barr, 2011, p. 256). A number of people change
jobs and careers and are without insurance for a period of time and
many college students do not have coverage in between the period
between graduation and full or partial employment (Barr, 2011, p.
256). Many self-employed may cancel their coverage for a period of
time and enroll with a new insurance carrier (Barr, 2011, p. 257).
The important point being that the 16.7 percent statistic of
Americans who are uninsured for the entire year does not include
those who are without insurance for a partial segment of the year.
In order to acquire a picture of who are the uninsured we must
realize that only 30.5 percent of the uninsured come from
low-income families (families with income less than $25,000) (Barr,
2011, p. 258). Consequently, almost half of those who have no
insurance are from families with a household income between $25,000
and $75,000 per year (Barr, 2011, p. 258). In regards to the age of
the uninsured, Barr (2011) informs us that forty-one percent of the
uninsured are young adults 18 and 34 (p. 258) and Fifteen percent
of the uninsured are children (Ibid). The Hispanic population of
this country comprises 32 percent of the uninsured,
14. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change the black population is 13 percent of the
uninsured and the Asian/Pacific Islanders make up 5 percent of the
uninsured (Barr, 2011, p. 258). Crucially, approximately 34 percent
of uninsured workers were employed full-time during the year (Barr,
2011, p. 259) and 35 percent of the uninsured were employed in
part-time work. Furthermore, only 31 percent of uninsured adults
did not work (Barr, 2011, p. 258). Barr (2011) brings to our
attention that the uninsured are not only the poor and the
unemployed (Barr, 2011, p. 260), rather the uninsured are mostly
from middle class, working families (Ibid). The employment related
aspects of the uninsured problem is rooted in the fact that low-
wage workers are not offered health insurance by their employers as
often as higher-wage workers (Barr, 2011, p. 260). In addition,
many low-wage workers simply cannot afford the health insurance
coverage that is offered through their place of employment although
many employers make coverage available (Barr, 2011, p. 260).
Furthermore, Kaiser Family Foundation and Health Research
Educational Trust (2010) estimated that in 2010 only 44 percent of
workers employed in firms with fewer than twenty-five employees
were covered by their employers health insurance (as cited in Barr,
2011, p. 261) as compared with 60 percent of employees in firms
with 25 to 199 employees, and 63 percent of employees in firms with
200 or more employees (Ibid). Barr (2011) reminds us that when
health care costs increase many at the margins of the health
insurance market lose coverage (p. 268). On the other hand, when
the economy is contracting, a falling GDP and rising unemployment
rate interchangeably will also lead to lower rates of
employment-based insurance.
15. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change A number of other factors compromise or act
as barriers in gaining access to high quality care (Barr, 2011, p.
273). As an example, Braveman et al. (1994) found that in a study
of patients that suffered from acute appendicitis, those who were
covered with either Medicaid or no insurance had approximately a 50
percent greater risk of developing a ruptured appendix than
patients with HMO coverage (as cited in Barr, 2011, p. 274). In
addition, those who were covered with a fee-for-service plan were
at a 20 percent increased risk of developing a ruptured appendix in
comparison to those on a HMO plan (as cited in Barr, 2011, p. 274).
Barr (2011) surmises that patients on HMO plan are required to
choose a primary care physician (PCP) upon joining and consequently
Having a previously identified provider can facilitate care in an
urgent situation (p. 275). On the other hand, patients on a
fee-for-service plan may delay finding a PCP and may end up finding
care in the emergency room (Barr, 2011, p. 275). In general,
patients on fee-for-service plans pay higher deductibles and
co-payments than those on HMO coverage that may lead to patients
delaying necessary care (Barr, 2011, p. 275). A further potential
barrier to care is the out-of-pocket expenses that a patient may
have to pay in order to secure medical services. Newhouse et al.
(1981) found an association between the amount a patient must pay
and the frequency with which the patient will obtain care (as cited
in Barr, 2011, p. 275). Barr (2011) concludes from this study that
when a patient is responsible for paying for part of the cost of
care, he or she is less likely to use that care. This association
applies to necessary care as well as to unnecessary care (p. 276).
A related barrier that emanates from economic/financial limitations
is experienced by Medicaid patients who are at times unable to
access care due to their particular insurance coverage. Here,
Asplin et al. (2005) conducted a study of patients that suffered
form a potentially serious medical problem (as cited in Barr, 2011,
p. 278) such as pneumonia, sever high blood pressure (Ibid). In
this
16. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change study when trained callers (graduate
students) would inform clinics and doctors offices (as cited in
Barr, 2011, p. 278) regarding their Medicaid insurance, only 34
percent of the time they would be able to receive an appointment
within a week. In contrast, callers who were trained to state that
they were covered by private insurance were able to get an
appointment for follow-up care within one week (as cited in Barr,
2011, p. 278). An additional barrier to care is rooted in the
racial characteristics of patients. When comparing white and black
patient who had suffered a heart attack and were seeking treatment
in a VA hospital, Peterson et al. (1994) found that among male
patientsblacks were significantly less likely than whites to
receive aggressive care involving revascularization (as cited in
Barr, 2011, p. 280). A number of other studies also have reported
racial differences in access to care (Barr, 2011, p. 280) and paint
a disturbing picture of continuing racial differences in access
(Ibid). Barr (2011) also states that For a variety of serious
medical conditions and in a variety of settings and geographic
locations, black patients receive less aggressive and lower-quality
medical care than white patients with the same disease. Even after
taking into account the type of insurance (p. 281). Barr (2011)
traces some of this unequal treatment of black patients to subtle
often unconscious bias (p. 284) that nonetheless can result in
lower-quality care for black and other minority patients (Ibid).
Lozano, Connell, and Koepsell (1995) and Rosenstreich et al. have
found that other barriers such as unsanitary and unhealthy living
conditions that lead some parents of children susceptible to asthma
attacks to rely more on the emergency room for care than the
doctors office (as cited in Barr, 2011, p. 285) also compromise
care. In addition, many patients in rural areas are not as close to
health care facilities (Barr, 2011, p. 286) in comparison to those
in urban areas and those in low income neighborhoods in urban
locations face a shortage and lack
17. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change of health care resources regardless of
insurance. All these barriers are also elevated with issues having
to do with securing transportation, child care and taking time off
work (Barr, 2011, p. 286). Cultural, ethnic and linguistic barriers
also compromise access to quality health care. U.S. Department of
Health and Human Services (2000, website) has mandated that all
health care providers that receive federal funds (Barr, 2011, p.
287) to provide language assistanceat no cost to each
patient/customer with limited English proficiency (as cited in
Barr, 2011, p. 287). Nevertheless, with respect to serving
multi-lingual care seekers, Blendon et al. (2007) have found
persistent problems in communication between patients and
physicians or other providers of care (as cited in Barr, 2011, p.
287) and many educators in the medical field and government
officials have called for better training of physicians and other
health care providers in what has come to be called cultural
competence (Barr, 2011, p. 287). Barr (2011) has referred to
organizational complexity (pp. 288-291) as a further barrier to
receiving quality health care. Here, Barr (2011) brings to our
attention that the managers of a human service organizationtend to
emphasize efficiency in the work of the organization (p. 290). In
this context, efficiency is measured on the basis of how many
patients have been seen or have received treatment per hour.
However, Barr (2011) argues that such a dynamic will create an
inherent conflict in the health care environment where a provider
is caught between the patients desire for good service and
managements emphasis on efficient work (p. 290). Eventually, Barr
(2011) contends this role conflict often leads to decreased worker
satisfaction and a tendency to become less sensitive to the needs
of patients (p. 290).
18. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change The Reforms of the Affordable Care Act
Intended to Expand Access, Improve Quality and Control Cost in the
Health Care System Under the Affordable Care Act (ACA) Medicaid
coverage is extended to all citizens and permanent residents with
incomes below 133 percent of FPL/Federal Poverty Level (Barr, 2011,
p. 271). ACA also provides a tax credit for those in between 133 to
400 percent of the FPL in order to facilitate the purchasing of
coverage from health benefit exchanges (HBEs), operated by the
state government or by a nonprofit organization (Barr, 2011, p.
271). In addition, under ACA, primary care physicians (PCPs) who
treat Medicaid Patients will be reimbursed 100 percent of the rate
paid by the Medicare program (Barr, 2011, p. 293) with the hope
that physicians who accept Medicare patients will also begin
accepting those who are covered under the Medicaid program. With
respect to entities that have a work force of more than 50
employees, ACA mandates that employers extend coverage to their
employees or pay a penalty of $2,000 for each staff member without
coverage (Barr, 2011, p. 271) All in all, approximately 32 million
people will begin gaining access to health insurance coverage under
ACA. ACA will invest heavily in the expansions of nonprofit
community health centers (Barr, 2011, p. 293). These organizations
are referred to as the federally qualified health centers (FQHCs)
(Barr, 2011, p. 293) that will receive additional funding in order
to treat Medicaid patients and hire extra staff members. ACAs
vision of FQHCs is to become a model of what the American Academy
of family Physicians, American Academy of Pediatrics, American
College of Physicians, and American Osteopathic Association (2007)
call patient-centered medical home (as cited in Barr, 2011, p. 293)
organizations by developing a team-based approach to the management
of chronic disease (Ibid) that will enhance the
comprehensiveness
19. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change of care, the continuity of care, and
ultimately the quality of care (Ibid). In addition, ACA has created
a new organization to studynew arrangement for care (Barr, 2011, p.
164) called the Center for Medicare and Medicaid Innovations
(CMMI). One of the concentrations of CMMI is to research strategies
for groups of physicians and hospitals to come together to form
accountable care organizations (ACOs) that will be responsible for
planning, coordinating, and providing the care of a group of
Medicare beneficiaries (Barr, 2011, p. 164) ACA has also mandated
that care providers must collect data on race, ethnicity, primary
language, disability status, and similar demographic
characteristics of the patients cared for (Barr, 2011, p. 293) in
order to evaluate racial and ethnic disparities in access to care
(Ibid). In regards to insurers, under ACA, companies are prohibited
from considering pre- existing conditions to deny coverage to an
applicant (Barr, 2011, p. 212). In addition, those who apply for
insurance must be charged a similar premium regardless of
pre-existing conditions (Barr, 2011, p. 212). Although some
exceptions are made in rate differentiation having to do with age,
tobacco use, participation in a health promotion program (Barr,
2011, p. 212), etc. Furthermore, ACA does not allow caps on the
amount an insurance plan will pay for care, either per year or for
a patients lifetime (Barr, 2011, p. 212). In order to address the
issue of health care cost escalation and particularly the rising
cost of Medicare, ACA has created the Independent Payment Advisory
Board (IPAB) that is composed of fifteen members appointed by the
president and confirmed by the Senate. IPAB will appraise/forecast
the rate of growth of Medicare spending on a per beneficiary basis
and compare that increase with the target rate of growth for this
federal program that will be estimated by ACA. The target rate of
growth set by the ACA for Medicare spending is based on the rate of
growth of the consumer price index (CPI) and the rate of growth of
the GDP. In the
20. Historical and CurrentTrendsin HealthCare that have Ledto
the Demandsfor Change event that the rate of growth of Medicare
spending is projected to exceed the target amount, IPAB is charged
with the responsibility of coming up with a plan to rein in
spending to meet the target amount (Barr, 2011, p. 164)).
Nevertheless, IPABs recommendations must not include any measures
that may ration health care, raise revenue [that is, taxes] or
Medicare beneficiary premiumsor increase Medicare beneficiary cost
sharing (including deductibles, coinsurance and copayments), or
otherwise restrict benefits or modify eligibility criteria (Barr,
2011, p. 164). Conclusion Our process oriented and transaction
based system of health care is in a state of cost escalation
crisis. At these rates of ever increasing expenditures other major
segments of our economy will suffer and the public sector will be
unable to support the fiscal viability of the health care system.
Nevertheless, in spite of this massive investment of financial
resources major issues remain concerned with the creation of an
effective, accountable, patient centered, quality laden and outcome
oriented system of delivering health care. One of the primary goals
of the Affordable Care Act (ACA) is to offer health insurance
protection to more than 50 million Americans who possessed no
coverage in the past. Through the creation of a number of
organizations and financial incentives in addition to the adoption
of several initiatives promoting patient satisfaction, provider
team work and increased communication among care givers ACA hopes
to improve quality, expand access and effectively manage the growth
of health expenditures.
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