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Public Health System
Jacqueline D. Laldee
Health Care Systems
Dr. Jonas Nguh
October 17, 2016
In the United States, economic factors shape the design of the health care system and drive healthcare provider practice. In this paper, the author posits that health care providers primarily focus on high-technology solutions to preventable disease conditions which has a positive effect on their bottom-line. As a result, there is blatant disregard for public health and a focus on the individual. The author describes medical errors should be monitored by the government. The author provides her opinion regarding the reason why an attempt to control either costs, access or quality worsens the remaining two variables
The driver of healthcare is individual/corporate profit and not the patient or the general population. Therefore, early detection and prevention of disease as well as public health are not a priority. Even as healthcare providers perform test after tests which may not add significant clinical value for financial gain, there is call to do more with less to maximize profits. Staffing mixes, available equipment, more complex care of sicker patients all contribute to increased risks for error. The root cause of these errors must be analyzed and solutions developed to prevent reoccurrence. The industry cannot be trusted to self-regulate and must be monitored due to conflict of interests; therefore, government oversight is needed. We must continue to use evidence-based clinical guidelines in conjunction to the clinical expertise of a physician to improve quality and contain costs.
The US Health System: public and private
Public health efforts and those of private medicine complement each other and together serve the spectrum of health service needs of American society. However, the relationship between public health efforts and those of private medicine has been contentious because public health focuses on the health of the population while private medicine focuses on the health of the individual. Additionally, the medical care culture encourages focus on secondary and tertiary prevention to arrest or reverse obvious disease condition in small numbers of individuals as opposed to preventative measures to minimize and/or prevent suffering in large populations.
Public health has difficulty maintaining its central role in promoting the health and well-being of the American people because of the healthcare provider-driven culture of second-level intervention with focus on high-technology solutions to preventable problems to maximize profits. In recent times, physicians have not even been very actively engaged in public projects to improve overall population health such as healthy lifestyle initiatives. Powerful lobbyists and special interest groups work diligently to promote the physician agenda. Public health has been cunningly linked to publicly funded help for the poor and; therefore, has not been favored by the general population. As the population ages and incidence of chronic diseases increases, the current health care system does not support the promotion and protection of public health. Unfortunately, it requires a new threat or epidemic to halt the demise of organized public health and restore an effective public health structure.
Hospitals and public health agencies both play an important role in detecting and responding to public health emergencies and such collaboration has been supported by public grants. In 2003, epidemiologists were placed in the largest hospitals in North Carolina to enhance communication between public health agencies and healthcare systems. In 2009, those epidemiologists helped develop hospital policies/protocols for the management of H1N1 based on surveillance data with state and federal guidance and educated hospital staff on these policies. The key stakeholders have reported high value in this collaborative effort both in routine daily practice and in responding to a major public health emergency (Markiewicz, Bevc, Hegle, Horney, & Davies, 2012). Similar programs should be instituted as part of a larger public health emergency preparedness and response system. Public health epidemiologists effectively link public health agencies and hospitals to enhance syndromic surveillance (early detection and identification of the pattern of outbreak of communicable diseases), communicable disease management, and public health emergency preparedness and response.
Health promotion and disease prevention, mandated by the Patient Protection Affordable Care Act of 2010, are best managed through primary care and public health services. The focus of the health care system should be on prevention and wellness, human resources, a sustainable health infrastructure, efficiency and effectiveness/performance measurement, and reduction of health disparities to improve the health of the entire population. An integrated system addressing personal and population health will lead to greater efficiency, cost savings, and better outcomes for patients and populations. However, an ongoing system in which stakeholders focus on their own individual/corporate financial gain is affecting quality of care. The focus of health care management is still on high-technology solutions to preventable disease conditions and healthcare providers must be redirected. The battle for universal coverage which, under a single payer source, can reduce duplicate, eliminate waste and fraud and cut administrative costs rages on. The estimated cost-savings of a single payer system in the United States is $400 billion annually. The savings is thought to be enough to provide comprehensive universal health care to all Americans (Walker, 2014).
Trust for America’s Health (TFAH) released A Healthier America 2013: Strategies to Move from Sick Care to Health Care in Four Years, which outlines recommendations to prioritize prevention and improve the health of Americans. The ten key public health issues identified are: reversing the obesity epidemic; preventing tobacco use and exposure; encouraging healthy aging; improving the health of low-income and minority communities; strengthening healthy women, healthy babies; reducing environmental health threats; enhancing injury prevention; preventing and controlling infectious diseases; prioritizing health emergencies and bioterrorism preparedness; and fixing food safety (Trust for America’s Health (TFAH)[ January 2013] ).
The “new federalism” movement that began at the end of Lyndon Johnson’s presidency, led to removal of federal responsibility for a national public system and signaled the beginning of Republican efforts to cut public health initiatives. In January 2000, the government met only 15% of the 319 targets established in 1990 (Sultz & Young, 2010). Although it appears that the government only gets involved when there is a new threat or epidemic, the federal government funds various initiatives such as National Institutes of Health (NIH), Food and Drug Administration (FDA), Center for Disease Control and Prevention (CDC), The Indian Health Services (HIS), Centers for Medicare and Medicaid, Agency for Healthcare Research and Quality (AHRQ), the Administration for Children and Families (ACF) and the Administration on Aging (AoA). Additionally, government-supported facilities treat the un-insured and those without access.
Addressing medical errors
The Institute of Medicine report of 1999 cites two major studies that establish medical errors as one of the leading causes of death and disability in the United States. Errors happen when something that was planned as part of medical care fails or when the wrong plan was used in the first place. Errors result from problems created by today’s complex healthcare system and from poor doctor-patient communication. Uninformed and uninvolved patients are less likely to follow the treatment plan to maximize outcomes. The National Academy of Science’s Institute of Medicine (IOM) that 44,000-98,000 deaths occur annually because of medical errors (Sultz & Young, 2010, p. 102). The federal government should take the necessary steps to monitor the status of this high-risk situation, as it does with other epidemics, and should not continue to trust the providers of health care to deal forthrightly with the problem of medical errors.
Error include failure to diagnose, misdiagnosis, surgical procedures, medication selection and/or dosages, service delays, system failures to include poor communication and lack of equipment. For example, the level of acuity of hospitalized patients is at an all-time high because only the sickest patients are hospitalized for shorter length of stays, as the number of complex patients receiving care in alternate outpatient settings dramatically rise; therefore, the intensity of care required has increased. Yet, physicians spend very little time with patients. New advanced equipment and more complex treatment plans increase the demand for specialized nursing care. Ancillary staff who do not have an equal body of nursing knowledge are utilized as a source of cheap labor. Nurses now frequently lead teams where they are responsible for the nursing process and patient outcomes. Good delegation and communication skills are needed to coordinate efficient and effective care. Staffing patterns and the hectic pace are conducive to increased error.
In 2008, the cost of medical errors that harmed patients was $17.1 billion. The most common errors were pressure ulcers, post-operative infections and post-laminectomy syndrome, persistent pain following back surgery. A total of ten types of errors account for more than two-thirds of the total cost of errors. Additional errors include surgery on the wrong patient or wrong site, foreign objects left in the body after surgery, catheter-relates urinary tract infections (UTIs), falls and trauma, mediastinitis (inflammation of the mid-chest) after open heart surgery and more (Van et al., 2011). Medical errors occur because of improper medical management. Hand-written physician orders may cause confusion and can often lead to medication errors. Patients have a reasonable expectation that they will not be harmed while receiving medical treatment.
Medical errors are increasing the costs of healthcare, extending hospital length of stays, causing death, disability, and distrust of the system. Medical errors are the 8th leading cause of death in the United States (Healey & McGowan, 2012, p. 19) There has been very little incentive to focus on making the work environment error free. Healthcare provider performance data should be available to the public so that people are able to compare health care and make informed decisions based on performance, costs, and quality. The release of this data in areas such as patient outcomes, compliance with national standards for preventative and chronic care, and comparative costs to the public brings the issue of healthcare quality to the forefront. After assessing the results of performance measurements, healthcare providers are expected to engage in performance improvement activities that enhance the patient care experience and patient outcomes. After all, continuous improvements help healthcare providers remain competitive. Thus, this publicly-released data can lead to successful health care reform. Effective performance measures can lead to payment reform and transform care.
States and communities are making data available for the purpose of measuring and improving healthcare in communities. Other key stakeholders are also working to make consistent and useful information about the quality and cost of health care widely available. Lack of consistency in findings can lead to lack of public confidence and patient/consumer withdrawal from the decision-making process. The stakeholders include federal agencies such as the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services (CMS); private, not-for profit organizations such as National Committee for Quality Assurance (NCQA); employers; labor groups; groups of physicians; hospitals; insurers; quality experts; and consumer organizations (Roski & McClellan, 2011).
Healthcare providers should not be left to self-regulate. When left unchecked, healthcare providers remain focused on personal/corporate financial profit to be gained from a patient’s illness as opposed to the patient himself/herself. Reporting errors may affect quality ratings and may result in financial loss and lawsuits against providers resulting in hesitation reporting errors. Therefore, the federal government should take the necessary steps to monitor the status of this high-risk situation, as it does with other epidemics, and should not continue to trust the providers of health care to deal forthrightly with the problem of medical errors.
The Centers for Medicare and Medicaid Services (CMS) calls safety issues "never events" that are preventable and should never happen. CMS has initiated a system of financial penalties for the occurrence of "never events. The link of finances to the reduction in medical errors is appropriate. The incentive for providers must become payment for good outcomes rather than payment for activities that are not necessary and may place the patient at great risk. Hospitals are being forced by non-reimbursement for medical errors to reduce these errors or risk financial losses. There is a real need to balance a desire to reduce cost and waste while focusing on quality improvement. This effort will include a system designed to prevent failed procedures or the wrong interventions. As third-party payers levy penalties due to medical errors, healthcare providers will be motivated to create service delivery systems that detect errors and correct those issues so that there is no reoccurrence to avoid financial losses (Healey & McGowan, 2010).
Healthcare professionals specializing in utilization management, case management and discharge planning focus on the entire patient. They routinely communicate with and read
documentation by many disciplines which puts them in a unique position to detect problems sooner than others might. Healthcare workers must be proactive, anticipate problems, report issues and advocate for the patient accordingly.
Legislative efforts to address costs, access and/or quality
Legislative attempts to address only one of the trio of rising costs, lack of universal access, or variable quality of health care only worsens the remaining two. An aging population, increasing prevalence of chronic diseases, escalating healthcare costs, economic instability, healthcare provider opposition, and increased coverage as a result of the Patient Protection Affordable Care Act of 2010 continue to pose challenge to the United States healthcare system.
We are the only highly-developed industrialized nation in the world that does not offer universal coverage. At the end of 2015, 28.5 million people remained without health coverage ( 2016). Universal coverage which, under a single payer source, can reduce duplicate, eliminate waste and fraud and cut administrative costs. The estimated cost-savings of a single payer system in the United States is $400 billion annually. The savings is thought to be enough to provide comprehensive universal health care to all Americans (Walker, 2014). We cannot afford universal coverage unless we fix care, and unless we make the whole cost of care more affordable, we cannot have better care and universal coverage. We must fix coverage first to be able to move forward. Focus on prevention and wellness, team-based care, integrated systems, efficiency, and appropriateness of care using evidence-based guidelines, adequate staffing, proper equipment, employee satisfaction, “pricing” vs. “costs” and using increased bargaining power to renegotiate the cost of goods can lead to cost-effective quality care.
The mandate to increase quality of care while lowering healthcare costs has forced the healthcare industry to re-assess the efficiency as well as effectiveness of care delivered. The focus of healthcare providers on individual success and financial rewards has been at the expense of the common good of society and has led to high healthcare costs and high levels of inequality in healthcare. Left to self-regulate, financial rewards have controlled physician practice and that of allied healthcare professionals including, but not limited to, where they practice, availability of specialty services, and the actual management of the patient. Despite having the highest healthcare cost per capita in the industrialized world, cost-effective quality care remains elusive. The healthcare industry has grown in ways that have led to misapplication of resources to include over-supply and deficits of personnel and available equipment/ technology, over-utilization and under-utilization, duplication of services, fragmented care, breakdown in transitions of care, and more.
While freedom of choice is an ideal that we all cherish as Americans, the benefits of “gatekeepers” should not be eliminated as completely open access would lead once again to a fee-for-service environment with escalating health costs driven by personal/corporate greed without emphasis on access or quality. The choice of medical services, provider and treatment options with little consideration of the costs and benefits to the patient does not convey cost effective quality care and is an unsustainable business model. Physician costs that are higher than the revenue brought in must be re-adjusted to ensure financial viability of the healthcare system.
Re-distribution of physician staff is needed. Additionally, advanced practice registered nurses (APRNs) are well-quipped to deliver cost-effective quality primary care services. Studies demonstrate that patient outcomes including physical and mental being, satisfaction and mortality, when seen by advanced practice registered nurses (APRNs), were equivalent to those seeing physicians. In fact, there was greater overall patient satisfaction, longer consultations and more testing done in many some instances. About 70-80% of advanced practice registered nurses (APRNs) practice in primary care – pediatrics, adult care, gerontology and/or midwifery (Naylor & Kurtzman, 2010). The American Medical Association and other powerful physician lobbyists groups continue to garnish political support to protect the interest of fellow physicians while limiting the use of non-physicians at the expense of the public’s health.
Standardization of care to include use of evidence-based clinical guidelines is crucial in the effort to control quality and cost. There must be increased focus on disease management, self-care efforts, to improve the overall health of those with chronic conditions. Medical resources to include personnel and equipment must be equally distributed and duplications of services eliminated. The law of supply and demand has had minimal of the dollar cost of healthcare. The distinction between “price” and “cost” must be made before better pricing can be negotiated. Additionally, a single payer source would have less administrative costs, more buying power and increased leverage to negotiate reduced cost of goods.
The capitalization of healthcare has resulted in higher costs using the fee-for-service model. Healthcare is best when driven by evidence-based guidelines used in conjunction with the clinical judgment of healthcare providers. Each case should be evaluated equitably on a case-by-case basis. The patient and population at large must be the primary focus. Aggressive continuous improvement activities must be imitated to eliminate medical errors is crucial. A single payer source may be a viable solution to reduce redundancy, eliminate fraud and waste, and cut administrative costs. References
(2016, September 29) Key Facts about the uninsured population. Retrieved from http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/
Halvorson, G. C. (2011, Winter). What We Need to Keep Healthcare Reform Moving in the Right Direction. The Journal of Health Administration Education, 28(8), 1-55. Retrieved from https://www.acponline.org/system/files/documents/advocacy/current_policy_papers/assets/controlling_healthcare_costs.pdf
Healey, B. J., & McGowan, M. (2010). The Enormous Cost of Medical Errors. Academy of Health Care Management Journal, 6(1), 17-24. Retrieved from http://search.proquest.com/docview/822773475?accountid=34574
Markiewicz, M., Bevc, C. A., Hegle, J., Horney, J. A., & Davies, M. (2012). Linking public health agencies and hospitals for improved emergency preparedness: North Carolina’s public health epidemiologist program. BMC Public Health, 12, 141. Retrieved from http://search.proquest.com/central/docview/1009159381/37C1FD15772249EFPQ/1?accountid=34574
Naylor, M. D., & Kurtzman, E. T. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29(5), 893-9. Retrieved from http://search.proquest.com/docview/304562994?accountid=34574
Roski, J., & McClellan, M. (2011, April). Measuring Health Care Performance Now, Not Tomorrow: Essential Steps To Support Effective Health Reform . Health Affairs, 30(4), 682-9. Retrieved from http://search.proquest.com/docview/864026139?accountid=34574
Sultz, H. A., & Young, K. M. (2010). Health Care USA: Understanding Its Organization and Delivery (7th ed.). Sudbury, MA: Jones & Barlett Learning.
Trust for America’s Health (TFAH). (2013, January). A Healthier America 2013: Strategies to Move from Sick Care to Health Care in Four Years. Retrieved from http://tfah.org/ assets/files/TFAH2013HealthierAmericaFnlRv.pdf
Van, D. B., Rustagi, K., Gray, T., Halford, M., Ziemkiewicz, E., & Shevre, J. (2011). The $17.1 billion problem: The annual cost of measurable medical errors. Health Affairs, 30(4), 596-603. Retrieved from http://search.proquest.com/docview/864025396?accountid=34574
Walker, J. B. (2014, January 29). Single-payer system would improve American health. Buffalo News, A6. Retrieved from http://search.proquest.com/central/docview/1492329048/CC71CB0D06AD4962PQ/8?accountid=34574
PUBLIC HEALTH SYSTEM 14
Running head: PUBLIC HEALTH SYSTEM 1
PUBLIC HEALTH SYSTEM 2RNs) practice in primary care – pediatrics, adult care, gerontology and/or midwifery (Naylor & Kurtzman, 2010). The American Medical Association and other powerful physician lobbyists groups continue to garnish political support to protect the interest of fellow physicians while limiting the use of non-physicians at the expense of the public’s health.
Halvorson, G. C. (2011, Winter). What We Need to Keep Healthcare Reform Moving in the Right Direction. The Journal of Health Administration Education, 28(8), 1-55. Retrieved from https://www.acponline.org/system/files/documents/advocacy/current_policy_papers/assets/controlling_healt