The US Healthcare System Impact on Equity, Efficiency and Effectiveness

Need vs. Demand and Utilization Need – an interpretation of an individual’s evaluated requirements for obtaining professional care through the health service system Demand – seeking out, but not necessarily receiving health services. Utilization – actual use of services. A result of need and demand

Health Care Spending in the U.S. In 2003, $1.7 trillion was spent on health care in U.S. In 2003, the United States spent 15.3 percent of its Gross Domestic Product (GDP) on health care. Compared to other countries: Switzerland – 10.9% Germany – 10.7% Canada – 9.7% France – 9.5% 45 million Americans were uninsured in 2003 Total out-of-pocket spending on health care rose $13.7 billion, to $230 billion in 2003.

Spending by Service in Health Care 2002 ServiceAmount Spent 2002 (in billions) Major cost factors Hospitals$486.5 (9.5% increase) Inflation; increase in patient volume Physicians$339.5 (7.7% increase) Medicare costs decelerated causing a reduction in the rate of growth in physicians spending Drugs$162.4 billion (15.4% increase) Rate “decelerated” from Out of pocket expenses increased.

Percent of health care expenditures 2002

Four Systems of Health Care Private, insured, middle-income Americans Poor, unemployed or under-employed Americans Active duty military personnel Veterans of military service

Private, insured, middle-income Americans Care is coordinated by physicians in private practice Care is funded by insurance (personal, non- governmental sources paid for by employer, individual or both) Characterized as an informal system of care Even though it is an informal system, patient has considerable control over their care It is also often poorly coordinated Medicare for the middle-income

Poor, Unemployed/Underemployed Families Without Insurance No formal system Majority of services are provided by local government agencies Patients have no continuity of service Poor must take whatever they can get Use of Medicaid & other government funded services

Military Medical System A well-organized system of “high quality” care at no direct cost to the recipient All inclusive and omnipresent System in effect whether personnel want it or not Emphasis is on keeping personnel well, prevention and early treatment of injury or illness It is a closely organized, highly integrated, rational and regionalized approach

Veterans Administration Health Care System Provides care to retired, disabled or other deserving veterans of military service History of VA is rooted in controversy Not as complete as other services Large number of male patients VA health system is just one of a system of social services and benefits for veterans Interest group representation 1990s represented a waning period for veterans and veteran services (“Snowbirds”) Future for the veteran

Brief History of Public Health Hippocrates and the Greeks The Middle Ages and the decline of public health The Renaissance and the re-emergence of lost knowledge The Enlightenment demonstrates the importance of a healthy population The Sanitary movement shows the importance of science and medicine The age of bacteria leads to vector control

Brief History of Public Health: Modern Times WWI introduced poison gas as warfare Draining of swamps reduces mosquito borne disease In 1919, “Spanish Flu” pandemic killed 30 million world-wide Fleming discovers penicillin in 1928 In WWII, protecting soldiers from disease leads to more death from injuries and wounds than from infection for the first time in history of wars The World Health Organization was formed in 1948 Salk invents the polio vaccine In 1978, smallpox is eradicated from the planet In 1979, the first cases of AIDS appear In 1980s, poison gas once again used in warfare (Iran-Iraq war) New diseases emerge: AIDS, SARS, drug-resistant staphylococcus

Public Health: Priorities for the Future Continue the pursuit of the eradication of disease and its causes Getting the public to understand that preventing disease does not rely solely on new medicine or inventions Making sure that we don’t undo the advances that we have already made

Blum’s Model of Factors Affecting Health Health Environment Fetal Physical Socio/Cultural Lifestyle Attitudes Behavior BiologyMedical Care Prevention Cure Care Rehabilitative

Infectious and Chronic Disease

Primary Cause of Death 1900

Primary Cause of Death 1997 Source: Healthy People 2010

Population characteristics and the use of healthcare service Person Measures Age Sex Ethnic group and race Social class/social-economic status

Prevention and Health Promotion Primary – inhibition of the development of the disease before it occurs Secondary – early detection and treatment of a disease Tertiary – the rehabilitation or restoration of effective functioning

Implications of an Aging Population Source: Williams and Torrens, 2002

Comparing U.S. with Other Countries

Selected Cause of Death:

Suicide Rate by Age, Sex and Race per 100,000

Firearm Related deaths per 100,000 in U.S. Source: Williams and Torrens, 2002

Years of Productive Life Lost before Age 65 among Children less than 20 Years

Relating Population Characteristics to Health System Characteristics Organization – to examine over- or under- utilization Personnel – the number of staff, their qualifications, and other manpower needs. Technology – which devices, procedures, pharmaceuticals are effective and efficient Programmatic efforts – examining the quality of services provided

Patient Visits per 100 persons by Ambulatory Service Type, and

Blum’s Model of Factors Affecting Health Health Environment Fetal Physical Socio/Cultural Lifestyle Attitudes Behavior BiologyMedical Care Prevention Cure Care Rehabilitative

Primary Cause of Death 1997 Source: Healthy People 2010

Healthcare Professionals Healthcare is a major employer It has a rapidly growing labor sector Professionals Non-professionals and technicians Non-institutional workers Rapid growth due to: Technology growth and specialization Health insurance coverage Aging population Emergence of hospitals

Types of Healthcare Worker Certification Licensure – state or legal designation Certification and registration Independent and dependent professions Independents practice without physician supervision (e.g., doctors, dentists) Dependents need physician supervision (most nurses, CNAs)

Physicians Comprised of two types by practice Primary care physicians – short supply in U.S. Family Practice, Internal medicine, OB/GYN, Pediatricians Specialists – Surplus in U.S. Specialize in specific areas

Physician Surplus or Shortage? Rapid growth of physicians, esp. specialists, during due to: Massive federal outlays Influx of International Medical Graduates (IMGs) Maldistribution of physicians can give appearance of shortage Not enough primary care providers Medical underserved areas in rural communities and inner cities Malpractice and the impact on physicians

Changing Role of the Physician More employed physicians By managed care organizations and hospitals (the emergence of the “Hospitalist”) Large group practices emerged with the growth of managed care Emphasis away from specialty areas to managed care More female physicians

Distribution of Physicians by Specialty: 1980, 1986, 1995, 2000 (In thousands Pct. Change SpecialtyNo./% No./% No./% No./% All specialties414/ / / / Primary Care159/ / / / Other Medical Specialties 25/6.2 62/ / / Surgical Specialties110/ / / / All other specialties118/ / / /

Will doctors meet demand in a bio- terror event

Nurses Typifies the concern of healthcare: “nursing is concerned with human response to health problems” Historic factors that shaped nursing as a career: Occupation to support physicians Emergence of hospitals as community institutions Acceptable female occupations, primarily white females Linked to religious orders

Understanding the Nursing Shortage Changes in occupational opportunities for women since 1970s Majority of RNs are 50+ years of age or married with children at home Low salaries – pay compression Burnout Lack of clinical career ladder Active vs. Inactive – about 1/3 of nurses not working fulltime

Ambulatory Care Personal health care given to the patient in an non-hospital or institutional setting Types of settings: Physician owned private practice Managed care clinic settings Community health care settings “Urgent care” facilities Shift to ambulatory care due to several factors: Medicare PPS Managed care Improved technology

Patient Visits per 100 persons by Ambulatory Service Type, and

Physician Authority Based on modern science and scientific knowledge. Physicians become the intermediaries between science and private experience Authority signifies the presence of status and quality Requires legitimacy and dependence. Legitimacy – acceptance by subordinates Dependence – bad things can happen if we don’t obey Types of Physician Authority Social Authority Cultural Authority Professional Authority

The Evolution of the Physician in the U.S. Allopathic Homeopathy Osteopathic Chiropractic

Physicians Comprised of two types by practice Primary care physicians – short supply in U.S. Family Practice, Internal medicine, OB/GYN, Pediatricians Specialists – Surplus in U.S. Specialize in specific areas

Physician Surplus or Shortage? Rapid growth of physicians, esp. specialists, during due to: Massive federal outlays Influx of International Medical Graduates (IMGs) Distribution of physicians gives appearance of shortage Not enough primary care providers Medical underserved areas in rural communities and inner cities Malpractice and the impact on physicians

Physicians: NV vs. US Physicians TypeNevadaU.S. Physician generalists per 100,000 population 2130 Physician specialists per 100,

Changing Role of the Physician More employed physicians By managed care organizations and hospitals (the emergence of the “Hospitalist”) Large group practices emerged with the growth of managed care Emphasis away from specialty areas to managed care More female physicians

Physicians who would recommend the practice of medicine

For physicians who wouldn’t recommend medical profession

Distribution of Physicians by Specialty: 1980, 1986, 1995, 2000 (In thousands Pct. Change SpecialtyNo./% No./% No./% No./% All specialties414/ / / / Primary Care159/ / / / Other Medical Specialties 25/6.2 62/ / / Surgical Specialties110/ / / / All other specialties118/ / / /

Physician Medical Education Undergraduate medical curriculum Most emphasize the acute care setting Increase in women and minorities Graduate medical education Major increases in residencies Shifts in the organization of medical schools Must compete for patients Shift to managed care by med school hospitals Trends medical education in for-profit hospitals Flexnor Report

Patient Visits per 100 persons by Ambulatory Service Type, and

Hospitals The growth of Hospitals in the U.S. is a fairly recent history: Hill-Burton Hospital Insurance Advances in medical science Professional nursing Improved medical school training for physicians Cost containment practices have lowered hospital utilization Decreased inpatient utilization through DRGs and managed care Shift to outpatient services System and specialty hospital growth

Hospital Classification For-profits – fastest growing type of hospitals For-profit and non-profit systems (e.g., Kaiser Permanente, Catholic Hospitals West) Public Hospitals Numbers are in decline Serve disproportionate number of Medicaid and uninsured Account for nearly 25% of uncompensated care Includes federally funded facilities such as VA and Armed Services facilities (McCallahan Federal Hospital)

Hospitals (types cont.) Academic teaching hospitals Tripartite mission Face shaky future Rural Hospitals Small, non-profit Many with nursing home swing beds Endangered Quality of care in question Types of services available being lost to cities

Number of Public Community Hospitals, U.S.

Constraining and Propelling Forces Affecting Hospital Constraining Governmental and third party purchaser pressure for cost containment Competition from multi-hospital systems and local physicians Conservatism of some traditionally oriented practicing physicians Cost of continuing technological advances Slower growth of the economy Changing governmental philosophy toward health care Propelling New health markets other than inpatient care Weakening power of physicians in the hospital New organizational structures Increasing power of a more business-oriented management team Aging of the population Changing customer expectations for service

Hospital Beds per 1,000 population by Ownership, 2002 NevadaU.S. State/Local Government Hospital Beds 17%16% Non-Profit Hospital Beds 32%71% For Profit Hospital Beds 51%13%

Background: Las Vegas Hospitals September, 2001 TotalGovt. (n=2) Private, For-Profit (n=6) Private, Non-Profit (n=3) Number of Hospital Beds Number of ER Beds Isolation Beds ER Clinicians Security Staff

Decontamination Capabilities and Personal Protection Equipment, 2001

Hospitals and Emergency Preparedness: Observation Areas and Data Collection

Mental Health Services Definition: Painful emotional symptoms…inability to think, remember or concentrate…increased potential of medical illness, pain, disability or even death Affects 30% of all adults Most mental illness is untreated 20-40% of homeless population is suffers from mental illness Mental illness is a crisis situation for Nevada hospitals

Percent Distribution of Mental Health 24-hour hospital and residential treatment beds

Who Gets Treatment for Mental Illness?