U.S. health care in conflict -- Part I: the challenges of balancing cost, quality and access. (Policy).The United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. health care system is a product of our unique social, political, economic and cultural environment and values. In the United States, we value pluralism This article is about the philosophical concept of value-pluralism. For other uses of the term see, see Pluralism. In philosophical ethics, value pluralism (also known as ethical pluralism or moral pluralism and choice, the market and competition, but are ambivalent and mistrustful of big government. We value individual freedom and the responsibility it entails. That translates into: "If people choose to be uninsured, it's their problem." We desire the latest technology, drugs and access to the best care immediately on demand, all at minimal cost to our own pocketbook. With its large number of payers and providers, growing consumer expectations complicate our pluralistic plu·ral·is·tic adj. 1. Of or relating to social or philosophical pluralism. 2. Having multiple aspects or parts: "the idea that intelligence is a pluralistic quality that ... system. That results in excessive overhead costs overhead costs see fixed costs. as compared to other countries. (1) Other developed countries face the same challenges of improving access and equity and reigning in costs while enhancing quality. Their health care systems reflect a unique approach based on their own environment and values, but all share some important differences from those of the United States. Social good Most other developed nations operate under the construct of health care as a "social good," which underlies the concepts of universal coverage and equity in access and services. (2) The concept of health care as a social good also leads to an understanding of why markets fail and an acceptance of a broader role for government in health care. Global budgets function as the mechanism of cost containment cost containment, n the features of a dental benefits program or of the administration of the program designed to reduce or eliminate certain charges to the plan. and result in rationing. In these systems, relatively unproven unproven Dubious, nonscientific, not proven, quack, questionable, unscientific adjective Relating to that which has not been validated by reproducible experiments or other scientific methods for determining effect or efficacy technologies, treatments and pharmaceuticals are not reimbursed if they fail to pass the tests of both efficacy and cost-effectiveness. Many health care policy experts assert that the central problem in our health care system is the lack of consensus on the major values that would serve as the basis for policy formulation. (23) In the United States, there is no societal consensus on issues like: * Is health care a right or a privilege? * Is health care a profession/public service, or a business subject to the market? * What is equity? Equal access? Equal benefits? Equal quality? In addition to the lack of the principles of social justice as a bottom line, the failure to distinguish between "health" and "health care" feeds our desire for access to the latest technology under the erroneous impression that new technology is what's responsible for our improved health. The reality is that health correlates most with socioeconomic factors such as education, income and access to basic services basic services, n.pl frequently insurance companies split dental procedures into basic and major categories. Basic services usually consist of diagnostic, preventive, and routine restorative dental services. . Throughout the health care debates in the mid-1990s over the Clinton health plan, these key principles were not adequately addressed. As a result, we have no current operational theory for health policy development and no strategies to reform the current system. Managed competition, the default policy under which we have operated for the past 20 years, has fallen into disfavor with both providers and consumers. The result is regulation that erodes managed care's ability to contain cost. As we head into the 21st century, we are faced with an explosion of expensive medical technology and pharmaceuticals, the emergence of information technology, an aging population and the arrival of the informed consumer. Along with the threat of rising costs comes the reality that our health care system will become even more tiered with a growing information gap, lack of insurance security and lack of access between the "haves" and the "have-nots." (4) Despite the clamoring clam·or n. 1. A loud outcry; a hubbub. 2. A vehement expression of discontent or protest: a clamor in the press for pollution control. 3. A loud sustained noise. about the speed of change in health care, we are still in the Ice Age compared to other industries. All of the reorganization has been around the fringes and focused on financing mechanisms rather than any serious restructuring of health care service delivery. Disparate values and the concepts of distributive justice DISTRIBUTIVE JUSTICE. That virtue, whose object it is to distribute rewards and punishments to every one according to his merits or demerits. Tr. of Eq. 3; Lepage, El. du Dr. ch. 1, art. 3, Sec. 2 1 Toull. n. 7, note. See Justice. have not been addressed. The United States health care system faces many challenges in trying to find a viable future. Among the critical issues are: * Achieving consensus on the constructs of health care as a public good and the definition of "equity" * Resolving the tension between health and health care * Reorganizing systems/communities of care to foster prevention, coordination and management of chronic conditions * Reducing clinical variation/ enhancing quality * Addressing the issue of the uninsured/underinsured * Finding a theoretical framework for health care financing and delivery * Addressing the solvency of the Medicare program * Financing new technology and drugs while limiting the rate of increase in health care costs * Managed care was ill-prepared to supply the leadership needed to address these issues and we still deliver care using ancient models and systems. Health care leadership lacks diversity, while stakeholders Stakeholders All parties that have an interest, financial or otherwise, in a firm-stockholders, creditors, bondholders, employees, customers, management, the community, and the government. trying to preserve the past pull policy formation apart. Physicians are tremendously resistant to structural change and are feeling disenchanted dis·en·chant tr.v. dis·en·chant·ed, dis·en·chant·ing, dis·en·chants To free from illusion or false belief; undeceive. [Obsolete French desenchanter, from Old French, and disenfranchised. Our small, incremental Additional or increased growth, bulk, quantity, number, or value; enlarged. Incremental cost is additional or increased cost of an item or service apart from its actual cost. successes continue to lead us down the same ineffective path, avoiding the difficult fundamental issues. Serious innovation will require new perspectives, new experiments and new connections. Global perspective Most developed nations are addressing the health care dilemmas of balancing cost, quality and access. Yet, even as countries move to contain costs, those with a history of universal access are retaining such coverage, even as they introduce market-based approaches into their health care systems. Universal coverage/access is maintained due to the underlying philosophy that health care is a public good rather than a market commodity. Nations that provide universal coverage do so through mandates and subsidization sub·si·dize tr.v. sub·si·dized, sub·si·diz·ing, sub·si·diz·es 1. To assist or support with a subsidy. 2. To secure the assistance of by granting a subsidy. . Graig notes that most health care systems contain a mix of these features and there is a constant balancing act between the roles of the public and private sectors. (5) Differences in these systems are growing less, as countries adapt processes that appear successful from other health care systems, usually market-based reforms akin to the American concept of managed competition, but managed by the government. (6) Despite health care expenses consuming 14 percent of the U.S. gross domestic product--far more than any other industrialized in·dus·tri·al·ize v. in·dus·tri·al·ized, in·dus·tri·al·iz·ing, in·dus·tri·al·iz·es v.tr. 1. To develop industry in (a country or society, for example). 2. nation--nearly 17 percent of Americans remain without health insurance (3,5) and many more are underinsured un·der·in·sure tr.v. un·der·in·sured, un·der·in·sur·ing, un·der·in·sures To insure under a policy that provides inadequate benefits: Be certain that you are not underinsured against catastrophic illness. . Graig points out in her review of the health care systems of several nations (U.S., Germany, Japan, Canada. United Kingdom and the Netherlands) "that the existence of national health insurance does not mean that the government controls the practice of medicine, nor does it necessarily involve limits on the patient's choice of provider." Yet, the U.S. appears to be operating under the misconception mis·con·cep·tion n. A mistaken thought, idea, or notion; a misunderstanding: had many misconceptions about the new tax program. that when the government mandates health insurance the government must also run it. American consumers continue to equate unregulated access to the latest technology with improved health, when in fact repeated research has shown that socioeconomic factors, education and access to basic care are more important because they more broadly impact health and health-related behaviors. (2,7) Wilkinson demonstrated that those countries with a narrower income distribution fared better on standard measures of health such as overall infant and maternal mortality. (8) In addition, few Americans think of themselves as having major responsibility for their health. Many others equate health with early discovery and treatment, not with lifestyle modifications. The growing body of knowledge of the determinants of health, although beginning to emerge in policy discussions, has had very little impact on the allocation of resources allocation of resources Apportionment of productive assets among different uses. The issue of resource allocation arises as societies seek to balance limited resources (capital, labour, land) against the various and often unlimited wants of their members. to achieve national health goals. In light of this, universal access to basic health care coupled with renewed efforts at broad public health initiatives remain key public policy issues requiring attention. Unless the United States can reach consensus on health care as a social good and apply an understanding of the determinants of health to policy formation and funding, any systemic reform process to address these issues is destined des·tine tr.v. des·tined, des·tin·ing, des·tines 1. To determine beforehand; preordain: a foolish scheme destined to fail; a film destined to become a classic. 2. to fail. Financing and delivery It appears an oxymoron to describe the organization, financing and delivery of health care in the United States Health care in the United States is provided by many separate legal entities. The U.S. spends more on health care, both as a proportion of gross domestic product (GDP) and on a per-capita basis, than any other nation in the world. Current estimates put U.S. as a system. Financing consists of a mix of public and private (both for-profit and not-for-profit) payers at federal, state and local levels, as well as a variety of sources of subsidy through public programs. Delivery is likewise a mix of for-profit, not-for-profit, public and private providers, including public clinics, county and municipal hospitals that make up the safety net for those without insurance or adequate finances. Welfare reform, variation among states, complex rules governing the eligibility for Medicaid and Medicare and the decrease in employer-based coverage all contributed to the growing number of uninsured and under insured. * In 1998, approximately 44.3 million people (16.3 percent of the population) were without health insurance for the entire year. (9) * Of those with insurance, 70.2 percent had private insurance, 62 percent from employers. * Medicare and Medicaid Medicare and Medicaid U.S. government programs in effect since 1966. Medicare covers most people 65 or older and those with long-term disabilities. Part A, a hospital insurance plan, also pays for home health visits and hospice care. covered 13.2 percent and 10.3 percent respectively. (10) * Part-time workers, minorities, those between the ages of 18-24, workers with lower incomes and those with lower educational attainment Educational attainment is a term commonly used by statisticans to refer to the highest degree of education an individual has completed.[1] The US Census Bureau Glossary defines educational attainment as "the highest level of education completed in terms of the were more likely to be uninsured or underinsured. (The underinsured either pay more out-of-pocket or go without care.) * One in eight families spends greater than 10 percent of its annual income on health care expenses. (11) * Regardless of the source of payment, the approximately 20 percent of people with chronic illnesses account for 80 percent of health care expenditures. (1) As the government tries to plug gaps in coverage through programs such as Medicare + Choice, the Health Insurance Portability and Accountability Act The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996. According to the Centers for Medicare and Medicaid Services (CMS) website, Title I of HIPAA protects health insurance coverage for workers and their families when (HIPAA (Health Insurance Portability & Accountability Act of 1996, Public Law 104-191) Also known as the "Kennedy-Kassebaum Act," this U.S. law protects employees' health insurance coverage when they change or lose their jobs (Title I) and provides standards for patient health, ), Children's Health Children's Health Definition Children's health encompasses the physical, mental, emotional, and social well-being of children from infancy through adolescence. Insurance Program (CHIPS) and potential expansions in state Medicaid programs, health insurance coverage continues to erode. Although he cites the loss of employer-based coverage as the most important factor in the rise of the un- and underinsured, Kuttner lists the following as contributing (12): * Rising premium costs * The trend toward temporary and part--time work * A reduction in covered benefits such as prescriptions * Greater limitations on covered care by HMOs thru denials and shifting costs to patients * The shift to plans requiring higher patient copayments * Loss of Medicaid coverage due to welfare reform * Rising cost of Medigap coverage for the elderly (Medicare covers on average only 50 percent of their health care costs) * Reductions in coverage for legal and illegal immigrants illegal immigrant n. an alien (non-citizen) who has entered the United States without government permission or stayed beyond the termination date of a visa. (See: alien) * The trend away from community rating of individual insurance premiums, pricing many out of coverage. In reality, HIPAA and COBRA (1985 Consolidated Omnibus Budget Reconciliation Act Consolidated Omnibus Budget Reconciliation Act, n.pr law that allows individuals to carry over health coverage from a previous job for a limited time at their own expense. ) provide little help in these situations. Together they prohibit denial of coverage and allow those leaving employment to continue to pay premiums out-of-pocket for 18 months, but neither addresses the economic barriers to coverage. They provide no subsidy to purchase insurance and do not regulate price leading to increased out-of-pocket costs out-of-pocket costs Managed care Health care costs that a covered person must pay out of pocket–eg, coinsurance, deductibles, etc. See Copayment. . Although still rising, the rate of increase in overall health care costs has slowed to 5 to 7 percent (1 to 2 percent above the GDP GDP (guanosine diphosphate): see guanine. ) over the last few years. Experts predict this slow rate of increase to continue over the next five years. (1) Major contributors to the rising costs include emerging medical technology and pharmaceuticals, information technology, unrealistic consumer expectations combined with little incentive to control costs, recent decisions regarding HMOs limiting choice of physicians/care, administrative expenses, duplication and inefficiencies, unnecessary care, oversupply o·ver·sup·ply n. pl. o·ver·sup·plies A supply in excess of what is appropriate or required. tr.v. o·ver·sup·plied, o·ver·sup·ply·ing, o·ver·sup·plies of physicians (especially specialists) and the aging of the population. Factors reducing costs include employers limiting health care benefits, Medicare changes in payment mechanisms and budget controls, Medicaid movement to the states (all of these will act to increase the number of uninsured and underinsured), providers achieving operational efficiencies, as well as a potentially greater focus on health and prevention. The pluralism and complexity of the U.S. health care system adds considerably to the costs, as estimates for marketing, management, administration and financial services The examples and perspective in this article or section may not represent a worldwide view of the subject. Please [ improve this article] or discuss the issue on the talk page. run from 25 to 30 percent, compared to 10 percent in Canada. (3) Unraveling managed care At one time, managed care and managed competition were embraced as the solution to health care service delivery. Enthoven and Ellwood created a vision of managed competition where vertically integrated health systems competed head to head on the basis of price and quality for informed consumers. (13) A mix of control and competition was expected to provide an incentive to integrated health systems to be both I efficient and high quality. It was also supposed to provide an incentive to cost conscious consumers to be prudent in their choice of health plans. Ultimately, health plans and integrated systems would be caring for a defined population with an incentive to care about the health and wellness of that population. However soon the HMOs found themselves only able to differentiate on the basis of price. Competing HMOs all had the same provider network. They came under considerable price pressure. Faced with the rising costs of pharmaceuticals and other innovations, they are experiencing rising medical loss ratios. At the same time, the purchasers of health care are pushing to keep premiums down. Although the movement to managed care is often given credit for health care cost-control in the early 1990s, another factor--the growth of Medicare through cost-shifting--also removed some of the cost burden from employers. Despite the fact that Medicare does not pay its full burden of health care costs, in the early and mid-1990s Medicare's payments rose faster than the costs of treating its beneficiaries. (14,15) For many providers, Medicare became their best payer. Enter the Balanced Budget Balanced budget A budget in which the income equals expenditure. See: budget. balanced budget A budget in which the expenditures incurred during a given period are matched by revenues. Act and the Balanced Budget Refinement Act and the cost shifting to Medicare can no longer occur. As capitation CAPITATION. A poll tax; an imposition which is yearly laid on each person according to his estate and ability. 2. The Constitution of the United States provides that "no capitation, or other direct tax, shall be laid, unless in proportion to the census, or is no longer growing, managed care with its high overhead is ill positioned to control costs. Health care plans, employers and employees will be playing the cost-shifting game and there is good reason to believe that employers will continue to shift the costs of health care to employees. Although mechanisms are evolving for consumers to assemble their own health care plans, without protections against adverse selection, unfair pricing and some premium support for lower income workers, the numbers without adequate coverage are likely to swell. Coddington feels that without federal action to address the inequities of health care financing by creating fair payment schemes for Medicare and Medicaid, and by providing some degree of payment for the uninsured, the health care system is likely to become destabilized. A system of universal coverage would reduce the need to cost shift. The health care industry--hospitals, physicians, and health plans--has been consolidating over the past 10 years, and with growing price and competitive pressures, there is reason to believe that this trend will continue over the next decade. As health plans consolidated, physician groups followed suit to gain contracting leverage. Hospitals and health systems consolidated to gain efficiencies and eliminate local competitors, but in many cases they failed to gain operating efficiencies and experienced the chaos of culture clash Culture Clash is the name of:
Shortell cites inability to prioritize pri·or·i·tize v. pri·or·i·tized, pri·or·i·tiz·ing, pri·or·i·tiz·es Usage Problem v.tr. To arrange or deal with in order of importance. v.intr. in the face of financial realities, misunderstanding of the integration strategy, shortage of appropriate talent and failure to relinquish control as major factors in the failure of many organizations to achieve seamless efficient systems of care. (16) Coddington, Fischer and Moore identify the characteristics of successful health care systems of the future, including: * Knowledge of and adherence to core values * Market segmentation Market Segmentation A marketing term referring to the aggregating of prospective buyers into groups (segments) that have common needs and will respond similarly to a marketing action. * New product development * Centers of excellence * Technological leadership * Disease management * Primary prevention * Teamwork among physicians and between physicians and the system * Process improvement * Superior customer service Part II of this article in the September/October issue of The Physician Executive journal will explore quality concerns and leadership challenges and offer a look at possible solutions to the health care conflict.. References (1.) coddington, DC, Fischer, EA, Moore, KD and Clarke, RL. Beyond Managed Care: How Consumers and Technology are changing the Future of Health care. San Francisco San Francisco (săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden , JoseyBass, 2000. (2.) Lee, PR and Estes, CL. The Nation's Health. Sudbury, Mass., Jones and Bardett, 2001. (3.) Morrison, I. Health care in the New Millennium. Vision, values, and Leadership. San Francisco, Josey-Bass, 2000. (4.) Institute for the Future. Health and Health care 2010: The Forecast, The challenge. San Francisco, Josey-Bass, 2000. (5.) Graig, LA. Health of Nations, Third Edition. Washington, D.C., Congressional Quarterly Congressional Quarterly, Inc., or CQ, is a privately owned publishing company that produces a number of publications reporting primarily on the United States Congress. , 1999. (6.) Saltman, R and Figueras, J. (Eds.) European Health care Reform. Copenhagen, Regional Office for Europe, World Health Organization, 1997. (7.) McKeown, T. "Determinants of Health." In Lee, PR and Estes, CL (Eds.), The Nation's Health. Sudhury, Mass., Jones and Bartlett, 2001, pp. 57-64. (8.) Wilkinson, RG. "Income Distribution and Life Expectancy Life Expectancy 1. The age until which a person is expected to live. 2. The remaining number of years an individual is expected to live, based on IRS issued life expectancy tables. ." British Medical Journal The British Medical Journal, or BMJ, is one of the most popular and widely-read peer-reviewed general medical journals in the world.[2] It is published by the BMJ Publishing Group Ltd (owned by the British Medical Association), whose other . Jan. 18, 1992, 304, (6820): 165-168. (9.) Campbell, JA. "Health Insurance Coverage: Consumer Income." In Lee, PR and Estes, CL (Eds.), The Nation's Health. Sudbury, Mass., Jones and Bartlett, 2001, pp. 313-320. (10.) United States Census Bureau The United States Census Bureau (officially Bureau of the Census as defined in Title ) is a part of the United States Department of Commerce. , 1999. (11.) Shearer, G. "Hidden from View: The Growing Burden of Health Care Costs." Washington, D.C., consumer's Union, 1998. (12.) Kuttner, R. "The American Health American Health Inc. is a company that manufactures health supplements. It is located in Holbrook, New York. One of its products is labeled the "Chewable Original Papaya Enzyme" with the attached registered trademark, "The 'After Meal Supplement'". Care System: Health Insurance Coverage." In Lee, PR and Estes, CL (Eds.), The Nation's Health. Sudhury, Mass., Jones and Bartlett, 2001, pp. 321-30. (13.) Enthoven, AC. "The History and Principles of Managed Competition." Health Affairs 1993. 12 (Suppl): 1993, 24-48. (14.) McLaughlin, N. "Blame On You." Modern Healthcare. Feb. 8, 1999, p. 57. (15.) Igelhart, JK. "The American Health Care System - Medicare." New England Journal of Medicine The New England Journal of Medicine (New Engl J Med or NEJM) is an English-language peer-reviewed medical journal published by the Massachusetts Medical Society. It is one of the most popular and widely-read peer-reviewed general medical journals in the world. . Jan. 28, 1999, 340(4), pp.327-32. (16.) Shortell, SM, Gillies, RB, Anderson, DA, Erickson, KM, and Mitchell, JB. 'Integrating Health Care Delivery." Health Forum Journal. Nov-Dec. 2000, 43(6): 35-39. Mary L. Dombovy, MD, is chair of PM&R for Unity Health System in Rochester N.Y. She can be reached by phone at 585/368-3002 or by e-mail at mdombovy@unityhealth.org. |
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