health care delivery system in the philippines essay

Essay on Health Care System In The Philippines

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100 Words Essay on Health Care System In The Philippines

The basics of health care in the philippines.

The Philippines’ health care system is a set of health services provided by public and private providers. Public health care is managed by the Department of Health (DOH), while private health services are offered by various hospitals and clinics.

Public Health Care

Public health care is available to everyone. It is funded by taxes and contributions from workers. The Philippine Health Insurance Corporation (PhilHealth) is the main public health care provider. It gives Filipinos access to basic medical services.

Private Health Care

Private health care is offered by private hospitals and clinics. It’s usually more expensive than public health care. People who can afford it often choose private care for more personalized service and shorter waiting times.

Challenges in the Health Care System

The health care system in the Philippines faces many challenges. These include a lack of resources, unequal access to health services, and a high cost of care. The government is working on these issues to improve the health care system.

Future of Health Care in the Philippines

The government aims to improve the health care system through the Universal Health Care Act. This law aims to provide all Filipinos with access to quality health care. It’s a big step towards better health care in the Philippines.

250 Words Essay on Health Care System In The Philippines

Introduction.

The health care system in the Philippines is a mix of public and private providers. It aims to give medical help to all its citizens. The Department of Health (DOH) is the main body in charge of health care.

The government provides health care through public hospitals and clinics. These are usually free or cost very little. The Philippine Health Insurance Corporation (PhilHealth) is the national health insurance program. It helps people pay for medical services.

There are also private hospitals and clinics. These usually offer better facilities and shorter waiting times. But, they are more expensive. Many people have private health insurance to help cover these costs.

The health care system in the Philippines faces some issues. There are not enough doctors and nurses, especially in rural areas. Also, the quality of care can vary greatly. Some people can’t afford the cost of private health care but need it due to the lack of public facilities.

Improvements

The government is working to improve the health care system. One step is the Universal Health Care Act. This law aims to give all Filipinos access to quality health care, without causing financial hardship.

In conclusion, the health care system in the Philippines is a mix of public and private providers. It faces some challenges, but efforts are being made to improve it. Everyone in the Philippines deserves access to good health care.

500 Words Essay on Health Care System In The Philippines

The basics of the health care system in the philippines.

The health care system in the Philippines is a mix of public and private providers. The Department of Health (DOH) is the main public health agency. It sets policies, plans, and programs for health services. It also runs special health programs and research.

The Philippine Health Insurance Corporation (PhilHealth) is another important part of the public health system. It provides health insurance for Filipinos. This helps to make health care more affordable.

Public and Private Health Providers

There are both public and private health care providers in the Philippines. Public providers include hospitals, clinics, and health centers run by the government. These offer free or low-cost services. But sometimes, they may not have enough resources or staff.

Private providers include doctors, clinics, and hospitals that are not run by the government. They usually offer more services and shorter waiting times. But, their services cost more.

Health Care Challenges

The health care system in the Philippines faces several challenges. One is the uneven distribution of health services. More health services are available in urban areas than in rural areas. This means people living in rural areas may have to travel far to get health care.

Another challenge is the cost of health care. Even though PhilHealth helps, many Filipinos still find health care expensive. Some may not be able to afford the medicines or treatments they need.

Efforts to Improve Health Care

The government is working to improve the health care system. In 2019, it passed the Universal Health Care Law. This law aims to give all Filipinos access to quality health care. It also aims to make health care more affordable.

The government is also investing in health technology. This includes telemedicine, which allows people to consult with doctors online. This can help people in rural areas get health care more easily.

The health care system in the Philippines is a mix of public and private providers. It faces challenges like uneven distribution of services and high costs. But, the government is taking steps to improve it. It is working to provide universal health care and make health care more affordable. It is also investing in health technology to reach more people. Despite the challenges, the future of health care in the Philippines looks hopeful.

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Sample details

Health Care

Health Care Delivery System

A health system, which can also be referred to as a health care system or healthcare system, is the organization of individuals, organizations, and resources that are responsible for providing healthcare services to particular populations (wikipedia.org, 2013). This delivery system comprises insurance companies, patients, physicians, hospitals, and other healthcare providers.

The main goal of the healthcare delivery system is to provide high-quality care at a lower cost. An important factor in choosing healthcare providers is understanding insurance concepts. Given the expensive nature of healthcare, it is crucial for individuals to have knowledge and understanding of their payment options. Consumers need to determine if they have an HMO, PPO, POS, or any other type of insurance plan.

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When enrolled in an HMO plan, individuals are required to use network providers and must obtain specialist referrals from their primary care physician. On the other hand, PPO and POS insurance plans provide out-of-network benefits at a higher expense. The government has a major role in the healthcare delivery system.

Stark’s 2012 report revealed that around 95 million individuals, approximately 31% of the total US population, received government assistance. To guarantee healthcare coverage for all American citizens, President Obama implemented the Patient Protection and Affordable Care Act in 2010. This legislation not only focused on offering health insurance but also included measures to prevent insurance companies from refusing coverage due to past medical records.

According to wikipedia.org (2013), healthcare providers, whether they are institutions or individuals, have a vital role in the delivery system as they offer various healthcare services. These providers can encompass Allied Health professionals like physicians, pharmacists, paramedics, nurses, and more.

Within the healthcare industry, there are different types of organizations such as hospitals, nursing homes, rehab facilities, home health providers, and durable medical equipment companies. The patient is an essential part of the overall healthcare delivery system. Recently, there has been increasing focus on preventive care.

Insurance companies now frequently cover the full expense of preventive care, as it has been demonstrated to be a cost-effective long-term approach. Healthy individuals are less costly in terms of healthcare expenses compared to those who are sick. Despite its notable deficiencies, the government is actively striving to enhance the healthcare system, recognizing that every component is essential for efficient functioning.

Reducing expenses and ensuring quality care are the main goals for the United States government in dealing with healthcare costs. The government plays a major role in the healthcare system, but while there are positive aspects to the Affordable Care Act, it is expected that it will ultimately place a significant financial burden on American citizens.

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Health care delivery system in the philippines.

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The Philippine Health Care Delivery Essay

This chapter discusses the related topics, the literature and studies reviewed as well; it also showed the theoretical, conceptual and analytical frameworks. Literature cited was bridged in the present study. Likewise, literatures cited were synthesized. Terms used in the study were defined for easy reference.

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Health care delivery.

The Philippine Health Care Delivery. Health care system is an organized plan of health services. The rendering of health care services to the people is called health care delivery system. Thus, health care delivery system is the network of health facilities and personnel which carries out the task of rendering health care to the people. In the Philippines health care system is complex set of organizations interacting to provide an array of health services. (www.freewebs.com/…/…).

In the Philippines the components of the health care delivery system as mandate of the Department of Health (DOH) is to be responsible for the following: formulation and development of national health policies, guidelines, standards and manual of operations for health services and programs; issuance of rules and regulations, licenses and accreditations; promulgation of national health standards, goals, priorities and indicators; development of special health programs and projects and advocacy for legislation on health policies and programs.The Philippine Health Care Delivery Essay. The primary function of the Department of Health is the promotion, protection, preservation or restoration of the health of the people through the provision and delivery of health services and through the regulation and encouragement of providers of health goods and services (E.O. No. 119, Sec. 3).

The DOH vision is “Health as a right. Health for All Filipinos by the year 2000 and Health in the Hands of the People by the year 2020.” While its mission is “DOH, in partnership with the people to ensure equity, quality and access to health care by: making services available; arousing community awareness; mobilizing resources; and promoting the means to better health. (www.freewebs.com/…/…).

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In the Philippine healthcare setting health care facilities are level as Level I, Level II, and Level III. Level I (Primary Level of Health Care Facility) are the rural health units, their sub-centers, chest clinics, malaria eradication units, and schistosomiasis control units are directly operated by the DOH; puericulture centers operated by League of Puericulture Centers; tuberculosis clinics and hospitals of the Philippine Tuberculosis Society; private clinics, clinics operated by the Philippine Medical Association; clinics operated by large industrial firms for their employees; community hospitals and health centers operated by the Philippine Medicare Care Commission and other health facilities operated by voluntary religious and civic groups.

The Level II (Secondary Level of Health Care Facilities) is the smaller, non-departmentalized hospitals including emergency and regional hospitals. The services offered to patients with symptomatic stages of disease, which require moderately specialized knowledge and technical resources for adequate treatment. While the Level III (Tertiary Level of Health Care Facilities) are the highly technological and sophisticated services offered by medical centers and large hospitals. These are the specialized national hospitals. The services rendered at this level are for clients afflicted with diseases which seriously threaten their health and which require highly technical and specialized knowledge, facilities and personnel to treat effectively. (www.freewebs.com/…/…). The Philippine Health Care Delivery Essay.

Health care workers are also classified. There are three levels of health workers in the Philippine. These are: the village or grassroots health workers; the intermediate level of health workers; and the first line hospital personnel. The village or grassroots health workers are the first contacts of the community and initial links of health care. They provide simple curative and preventive health care measures promoting healthy environment and participate in activities geared towards the improvement of the socio-economic level of the community like food production program. These are the barangay health worker, volunteers or traditional birth attendants or hilot.

The intermediate level of health workers represents the first source of professional health care. They attend to health problems beyond the competence of village workers and provide support to front-line health workers in terms of supervision, training, supplies, and services. These are the medical practitioners, nurses and midwives. While the first line hospital personnel provide backup health services for cases that require hospitalization and establish close contact with intermediate level health workers or village health workers. These are the physicians with specialty, nurses, dentist, pharmacists, and other health professionals. (www.freewebs.com/…/…).

Parts of the healthcare setting are patients. A patient is any recipient of healthcare services. According to Wikipedia, the patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider. The word patient originally meant “one who suffers”. This English noun comes from the Latin word patiens, the present participle of the deponent verb, patior, meaning ‘I am suffering,’ and akin to theGreek verb Ï€Î¬ÏƒÏ‡ÎµÎ¹Î½ (= paskhein, to suffer) and its cognate noun Ï€Î¬Î¸Î¿Ï‚ (= pathos) (en.wikipedia.org/wiki/Patient).

Patients’ satisfaction with an encounter with health care service is mainly dependent on the duration and efficiency of care, and how empathetic and communicable the health care providers are. It is favored by a good doctor-patient relationship. Also, patients that are well informed of the necessary procedures in a clinical encounter, and the time it is expected to take, are generally more satisfied even if there is a longer waiting time. (Pulia, 2011)

Patient Satisfaction

Patient satisfaction represents a complex mixture of perceived need, expectations and experience of care. “Quality healthcare” can cover a wide spectrum. It may be structural quality which relates to dimensions such as continuity of care, costs, accommodation and accessibility; while process quality involves the dimensions of courtesy, information, autonomy and competence. The terms “service quality” refer to a set of issues including communication, sign posting, information provision and staff interaction with patients. Interpersonal aspects of quality and amenities of care together with the technical aspects of quality to be the three components of health care quality. The interpersonal component of quality is defined as the quality of interaction between the patient and provider or the responsiveness, friendliness, and attentiveness of the healthcare provider.

Patient satisfaction focuses on clinical interaction in specific healthcare settings whereas responsiveness evaluates the health system as a whole. Patient satisfaction generally covers both medical and non-medical aspects of care while responsiveness focuses only on the non-health enhancing aspects of the health system. Patient satisfaction represents a complex mixture of perceived need, individually determined expectations and experience of care.

Satisfaction is a relative judgment. It is a comparison between perceived performance and aspiration. The basic point to asses’ satisfaction is to measure the extent to which aspirations are met given the self perceived performance level. Both the level of aspiration and of perceived performance has to be measured. The Philippine Health Care Delivery Essay. This is necessary because aspirations may be unrealistic given the level of available resources while evaluation of performance levels by individuals may differ widely from the actual or objective levels of achievement.

Patient-related factors. A citied in the study of Thiedke (2007) patients’ demographic and social factors are a minor factor in patient satisfaction, while others concluded that majority of the demographics represent the variance in rates of satisfaction. On the other hand, the literature does shed some light on how particular demographic factors affect patient satisfaction. The most consistent result was the finding of Haviland, et. al., (2006), which was older patients tend to be more satisfied with their health care. Studies that have looked at ethnicity have generally held that being a member of a minority group is associated with lower rates of satisfaction. Most studies have found that individuals of lower socio economic status and less education tend to be less satisfied with their health care. However, the study of Kersnik, et, al, (2001) found that frequent visitors to a family practice had lower educational status, lower perceived quality of life, and higher anxiety and depression scores and were more satisfied with their family physician. Other studies have shown that poorer satisfaction with care is associated with experiencing worry, depression, fear or hopelessness (Frostholm, 2005), and having a psychiatric diagnosis such as schizophrenia, post-traumatic stress disorder or drug abuse (Desai 2005).

Physician-related factors. According to literature physicians can promote higher rates of satisfaction by improving the way they interact with their patients. Possibly the most important characteristics of a physicians is to take the time and effort to elicit patients’ expectations. A study of Rao, et. al., (2005) shows that when physicians recognize and address patient expectations, satisfaction is higher not only for the patient but also for the physician; it may help to remember that patients often show up at a visit desiring information more than they desire a specific action. In addition, Bell, et. al. (2001) found out that approximately few patients had one or more unvoiced desires in a visit with their physician. The desire for a referral or for physical therapy was the most common. Young and undereducated patients were more likely to experience unmet needs at their visit, and they demonstrated less symptom improvement and evaluated their visit less positively. The Philippine Health Care Delivery Essay.

Communication. Shaw, and his colleague (2005) presented that doctor-patient communication can also affect rates of satisfaction. When patients who presented to their family physician for work-related, low-back pain felt that communication with the physician was positive (i.e., the physician took the problem seriously, explained the condition clearly, tried to understand the patient’s job and gave advice to prevent re-injury), their rates of satisfaction were higher than could be explained by symptom relief. As cited by Thiedke, (2007) in his study physicians can also improve patient satisfaction by relinquishing some control over the encounter. Studies have found that when physicians exhibited less dominance by encouraging patients to express their ideas, concerns and expectations, patients were more satisfied with their visits and more likely to adhere to physicians’ advice. Thus, Patient satisfaction can also be influenced by physicians’ medical decision making. Patients expressed a preference for physicians who recognized the importance of their social and mental functioning as much as their physical functioning.

The Webster’s Dictionary defines communication as “the imparting or interchange of thoughts, opinions, or information by speech, writing, or signs.” Whereas the spoken words contain the crucial content, their meaning can be influenced by the style of delivery, which includes the way speakers stand, speak, and look at a person (Joint Commission Resources; 2005). The collaboration in health care is defined as health care professionals assuming complementary roles and cooperatively working together, sharing responsibility for problem-solving and making decisions to formulate and carry out plans for patient care.

Collaboration between physicians, nurses, and other health care professionals increases team members’ awareness of each others’ type of knowledge and skills, leading to continued improvement in decision making. Effective teams are characterized by trust, respect, and collaboration, one of the greatest proponents of teamwork. Teamwork, is believes, to be endemic to a system in which all employees are working for the good of a goal, who have a common aim, and who work together to achieve that aim. When considering a teamwork model in health care, an interdisciplinary approach should be applied. Unlike a multidisciplinary approach, in which each team member is responsible only for the activities related to his or her own discipline and formulates separate goals for the patient, an interdisciplinary approach combine a joint effort on behalf of the patient with a common goal from all disciplines involved in the care plan.

The pooling of specialized services leads to integrated interventions. The plan of care takes into accounts the multiple assessments and treatment regimens, and it packages these services to create an individualized care program that best addresses the needs of the patient. The Philippine Health Care Delivery Essay. The patient finds that communication is easier with the cohesive team, rather than with numerous professionals who do not know what others are doing to manage the patient.

It is important to point out that fostering a team collaboration environment may have hurdles to overcome: additional time; perceived loss of autonomy; lack of confidence or trust in decisions of others; clashing perceptions; territorialism; and lack of awareness of one provider of the education, knowledge, and skills held by colleagues from other disciplines and professions. However, most of these hurdles can be overcome with an open attitude and feelings of mutual respect and trust. A study determined that improved teamwork and communication are described by health care workers as among the most important factors in improving clinical effectiveness and job satisfaction. (Flin, et. al., 2003)

Extensive review of the literature shows that communication, collaboration, and teamwork do not always occur in clinical settings. For example, a study by Sutcliff, Lewton, and Rosenthal (2004) reveals that social, relational, and organizational structures contribute to communication failures that have been implicated as a large contributor to adverse clinical events and outcomes. Another study shows that the priorities of patient care differed between members of the health care team, and that verbal communication between team members was inconsistent (Flin, 2003). Other evidence shows that more than one-fifth of patients hospitalized in the United States reported hospital system problems, including staff providing conflicting information and staff not knowing which physician is in charge of their care (Cleary, et. al., 2003).

Over the past several years, we have been conducting original research on the impact of physician and nurse disruptive behaviors (defined as any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical or sexual harassment) and its effect on staff relationships, staff satisfaction and turnover, and patient outcomes of care, including adverse events, medical errors, compromises in patient safety, poor quality care, and links to preventable patient mortality. Many of these unwanted effects can be traced back to poor communication and collaboration, and ineffective teamwork (Rosenstein, et. al., 2005).

Unhappily, many health care workers are used to poor communication and teamwork, as a result of a culture of low expectations that has developed in many health care settings. This culture, in which health care workers have come to expect faulty and incomplete exchange of information, leads to errors because even conscientious professionals tend to ignore potential red flags and clinical discrepancies. They view these warning signals as indicators of routine repetitions of poor communication rather than unusual, worrisome indicators. (Chassin, 2002) The Philippine Health Care Delivery Essay.

Although poor communication can lead to tragic consequences, a review of the literature also shows that effective communication can lead to the following positive outcomes: improved information flow, more effective interventions, improved safety, enhanced employee morale, increased patient and family satisfaction, and decreased lengths of stay. (Joint Commission Resources, 2005). Gittell and others (2000) show that implementing systems to facilitate team communication can substantially improve quality. Effective communication among staff encourages effective teamwork and promotes continuity and clarity within the patient care team. At its best, good communication encourages collaboration, fosters teamwork, and helps prevent errors.

In health care environments characterized by a hierarchical culture, physicians are at the top of that hierarchy. Consequently, they may feel that the environment is collaborative and that communication is open while nurses and other direct care staff perceive communication problems. Hierarchy differences can come into play and diminish the collaborative interactions necessary to ensure that the proper treatments are delivered appropriately. When hierarchy differences exist, people on the lower end of the hierarchy tend to be uncomfortable speaking up about problems or concerns. Intimidating behavior by individuals at the top of a hierarchy can hinder communication and give the impression that the individual is unapproachable (Joint Commission Resources, 2005; Weick, 2002 ) .

Staff who witness poor performance in their peers may be hesitant to speak up because of fear of retaliation or the impression that speaking up will not do any good. Relationships between the individuals providing patient care can have a powerful influence on how and even if important information is communicated. Research has shown that delays in patient care and recurring problems from unresolved disputes are often the by-product of physician-nurse disagreement. Several results of research has identified a common trend in which nurses are either reluctant or refuse to call physicians, even in the face of a deteriorating status in patient care. Reasons for this include intimidation, fear of getting into a confrontational or antagonistic discussion, lack of confidentiality, fear of retaliation, and the fact that nothing ever seems to change. Many of these issues have to deal more with personality and communication style (Rosenstein. 2002). The major concern about disruptive behaviors is how frequently they occur and the potential negative impact they can have on patient care. Our research has shown that 17 percent of respondents to our survey research in 2004-2006 knew of a specific adverse event that occurred as a result of disruptive behavior.The Philippine Health Care Delivery Essay. A quote from one of the respondents illustrates this point: “Poor communication” postop because of disruptive reputation of physician resulted in delayed treatment, aspiration, and eventual demise.” (Rosenstein, 2005)

Time spent. Time spent during a visit plays a role in patient satisfaction, with satisfaction rates improving as visit length increases. Time spent chatting during the visit was also related to higher rates of satisfaction. Physicians with high-volume practices were more efficient with their time but had lower rates of patient satisfaction, offered fewer preventive services and were viewed as less sensitive in the doctor-patient relationship (as cited by Thiedke, 2007). Interestingly, one study showed that while physicians felt rushed 10 percent of the time, patients felt that way only 3 percent of the time. Patient satisfaction was identical whether the physician did or did not feel rushed. This suggests that physicians may be more sensitive to feelings of being rushed and their feelings may not reflect the actual time spent during the visit. (Lin, et. al., 2001)

Technical skills/quality. In the healthcare delivery, healthcare quality has two distinct facets: technical quality (also called quality in fact) and functional quality. Technical quality refers to the accuracy of medical diagnoses and procedures, and is generally comprehensible to the professional community, but not to patients. Study conducted by Jaipul (2003) patient perceives functional quality as the manner in which the service is delivered. Functional quality perceptions may influence future decisions to return to a facility for service. Some empirical evidence suggests that patients’ quality judgment may be positively associated with technical quality, as reflected in outcomes such as risk-adjusted mortality among hospitalized patients for medical conditions (Lin, et. al., 2002).

Technical quality cannot be attained without the technical skills of the health care personnel. The study conducted by Chang, et. al. (2006) has looked at patients’ assessment of their physicians’ technical skills and the effect on satisfaction, but the findings are contradictory. However, Fung, et. al., (2005) study found that when forced to make a trade-off, participants expressed a strong preference for physicians who have high technical skills. Otani, et. al., (2005) findings revealed that patients also indicated that a physician’s ability to make the correct diagnosis and craft an effective treatment plan were more important than his or her “bedside manner.”

System-related factors. Patient satisfaction is not simply a product of the patient’s demographics and the physician’s skills. It is also affected by the system in which care is provided. Otani’s (2005) findings disclosed that although it is clear that patients’ first concern is their doctor, but they also value the team with which the doctor works with. One study (Wolosin, et, al., 2005) found that while physician care was most influential to patients’ satisfaction, the compassion, willingness to help and promptness of the physician’s staff were next in importance. In another large database of surveys, nurses were the next most important source of satisfaction, ahead of access-to-care issue. Patients who had remained in a practice for more than 15 years attributed their loyalty to their physician first and to the “team concept” second as cited by Thiedke (2007). Effective referrals play a role in patient satisfaction (Roseanne et. al., 2006) . One study looked at referrals from the standpoint of the family physician, the referral physician and the patient, and found that satisfaction with the referral’s outcome was higher when the family physician initiated the referral (Bekkelund , et. al., 2005). Similarly, a study of patients treated for recurring headaches revealed that those who self-referred to a neurologist were less satisfied than those whose primary doctor had referred them. A survey of cancer patients found that they valued their family physician highly and wanted to maintain contact with him or her, even when they were receiving cancer care elsewhere (cited by Thiedke 2007). The Philippine Health Care Delivery Essay.

Donahue, et. al. (2005) states that continuity of care, one of the pillars of family medicine, is felt to have suffered under managed care Norman, et. al., (2001). While it is unclear to what degree patients in general value continuity of care, it is clear that patients who have been followed by their physician for more than two years are more satisfied with their care – particularly when they are able to see their own physician (Gary, et. al, (2005). Beach et. al.. (2005) exposed that patients who reported being treated with dignity and who were involved in decisions were more satisfied and more adherent to their doctor’s recommendations. Stelfox, et. al, (2005) exposed that patient satisfaction surveys of inpatient physician performance showed an inverse relationship between satisfaction and risk management episodes. In addition, physicians can find practical take-away lessons in the literature, such as the following: treat patients with dignity and include them in decision making; work with a team; elicit patients’ concerns; and dress in semiformal attire and always smiling. Lastly, while it may not be as easy as the above lessons, find pleasure in what you do. Physicians who report high professional satisfaction have patients who are more satisfied with their care. (Haas, et. al., 2000).

Synthesis of the Arts

Studies of Thiedke (2007), Haviland, et. al., (2006), Haviland, et. al., (2006), Frostholm (2005), and Desai (2005) studied if there is significant relationship between demographic profile and patient’s satisfaction. Studies of Rao, et. al., (2005), and Bell, et. al. (2001) focused on the physician-related factors of patient satisfaction. This patient satisfaction was attributed in recognizing and addressing patient expectations while Bell, et. al. (2001) looked into the desire for a referral or for physical therapy as the reason for patient satisfaction.

Shaw, and his colleague (2005), Thiedke (2007), Flin, et. al., 2003, Sutcliff, Lewton and Rosenthal (2004), Chassin (2002), and Rosenstein, et. al., 2005 presented that doctor-patient communication can also affect rates of satisfaction. Extensive review of the literature shows that communication, collaboration, and teamwork do not always occur in clinical settings. An example was the study by Sutcliff, Lewton, and Rosenthal (2004) reveals that social, relational, and organizational structures contribute to communication failures that have been implicated as a large contributor to adverse clinical events and outcomes.

Jaipul (2003) and Lin, et. al., (2002) studied on the technical quality (also called quality in fact) and functional quality. While the study conducted by Chang, et. al. (2006), and Fung, et. al., (2005), and Otani (2005) has looked at technical skills of the health workers. The Philippine Health Care Delivery Essay.The study of Otani (2005) also center on system related factor such as teamwork of other health professional, Wolosin, et. al., (2005) stress that compassion and willingness to help of the health care professions, Bekkelund, et. al., (2005) and Roseanne et. al., 2006 disclosed referrals as factors that persuade patient satisfaction. Donahue, et. al. (2005), Norman, et. al. (2001) states that continuity of care are factors that offer patient satisfaction. (Gary, et. al, (2005), Beach et. al.. (2005), Stelfox, et. al., (2005), and (Haas, et. al., 2000), exposed that patients who reported being treated with dignity, as factors that influence patient’s satisfaction.

Gaps Bridged by the Study

While most of the literature cited which had been reviewed concerned whether there is relationship between demographic profile and patient’s satisfaction, physician-related factors addressing patient expectations the desire for a referral or for physical therapy was the reason for patient satisfaction. Extensive review of the literature shows that communication, collaboration, and teamwork do not always occur in clinical settings. Technical quality, technical skills of the health workers, communication and teamwork of other health professional, compassion and willingness to help, patients who reported being treated with dignity as factors that influence patient’s satisfaction were also studied. However, there is no research yet conducted on the same topic and on the recommendations to have quality management program of the healthcare services at Dr. Fernando B. Duran Sr. Memorial Hospital (DFDMH).

Theoretical Framework

This study will be anchor to Expectation Fulfillment Theory by Linder-Pelz (1982). Expectations, which are central to the consumer model, play in determining satisfaction with healthcare. The work of Linder-Peltz on the interaction between patient expectations and perceptions is seen to be particularly influential in this respect. Linder-Peltz’s viewed expectations have an effect on satisfaction independent of other variables (i.e., irrespective of their fulfillment) leading to conclude that this is not to say that expressions of satisfaction have little to do with the qualities of the service provided or the care offered and clearly “engendering positive expectations’ must not be confused with raising false hopes which deliberately mislead patients. The Philippine Health Care Delivery Essay. Even so, the assumption that satisfaction is entirely the product of an evaluation by itself but it may not apply in all situations.

In this regard Zeithaml, et. al., (1990) have noted that while consumers ultimately judge the quality of services on their perceptions of the technical outcome provided and how that outcome was delivered (process quality), many professional services are highly complex and a clear outcome is not always evident. This is certainly true of many healthcare scenarios where the technical quality of the service- the actual competence of the provider or effectiveness of the outcome – is not easy to judge. The patient may never know for sure whether the service was performed correctly or even if it was needed in the first place. Williams (1994) has observed that the greater the perceived unexplained or technical nature of treatment the more likely it is that many service users will not believe in the legitimacy of holding their own expectations, or of their evaluations (Zelthaml, et. al., 1990).

In addition, if a service user is coming into contact with the system for the first time then expectations, which for many have been formed through past experience, might be waiting formation. In both cases a patient might wish for the health professional to adopt a paternalistic role in the relationship (‘doctor knows best’) while they themselves remain a passive partner. Donabedian (1980) sees quality of healthcare as a trilogy comprising ‘structure, process and outcome'( Zeithaml, et. al., 1990). However, Shaw (1984) argue that service users who cannot judge the technical quality of the outcome effectively will base their quality judgments on structure and process dimensions such as physical settings, the ability to solve problems, to empathies, time-keeping, courtesy and so on.

This study is also anchored on Lydia Hall’s Care, Core and Cure theory. The CARE focuses on hands-on bodily care and the belief that a caring touch and thorough assessment is therapeutic. This nurturing component which is also referred to as “mothering” the patient, is done with the goal of comforting the patient and helping them meet their needs. The “motherly” care provided by nurses and the medical staff may include, but is not limited to provision of comfort measures, provision of patient teaching activities and helping the patient meet their needs where help is needed. The members of the staff help the patient or the family in accepting and adapting to the emotional and other stresses the condition may bring. It also opens channels of communication to allow expression of feelings and help the patient/family work out through it.The Philippine Health Care Delivery Essay. Thus, it is utilized when patient is provided with care and teachings at each phase of the nursing process, providing him/her with comfort both physiologically and psychosocially.

According to the theory, the CORE is the person or patient to whom nursing care is directed and needed. The core (patient) has goals set by him/herself and not by any other person, and that these goals need to be achieved. The “core”, in addition, behaved according to his feelings, and value system. In Hall’s theory, “core” refers to using therapeutic communication to help the patient understand not only his condition, but also his life. The goal is to help patients learn their roles in the healing process. Thus, it is realized when the patient is able to express his/her feelings about the procedure and participates in exploring these feelings, helping him/her towards a faster recovery.

The CURE, on the other hand is the attention given to patients by the medical professionals. It refers to the medical staff applying their knowledge of the disease to assist with a plan of care. Their function is to assist the patient and her family in coping with treatment. When the care, core and cure exhibit harmony and balance, the patient will be the one to benefit from it all since his/her needs are being put into priority.

The nursing care model of Virginia Henderson was also used as basis of the study. Using the Henderson’s model of the concept of nursing provides the understanding that nursing care should be holistic and contemplate the patient as a whole with his/her physical aspects as well as psychical, emotional, cultural and spiritual ones. According to Henderson, the person as whole has 14 basic activities or requisites to be satisfied in order to maintain a person’s health and well being, and develop all his/her capacities. These 14 components are: Breathe normally, Eat and Drink Adequately, Eliminate Body Waste, Maintain Desirable Positions, Sleep and Rest, Wear Suitable Clothes, Maintain Body Temperature by adjusting clothes and modifying environment, Keep the Body clean and well-groomed, Avoid Dangers and Injuring Others, Communicate with others, express emotions, needs and fears, Worship according to one’s faith, Work to have a sense of Accomplishment, Play and Participate in various forms of Recreation, Learn, discover and Satisfy Curiosity. According to this model, everybody is capable of carrying out these basic activities by themselves, and if they don’t, it is because of lack of the knowledge, will, or strength to do so.

According to this model, nursing care should be centered on the individual and based on a dynamic relationship between patient and nurse, as well as having a teaching function (George, 2000). Although each individual is unique, the fundamental needs of every human being are of a similar nature. The task of the nurse is to assist patients in articulating their needs, interests and wishes. The nurse should help each patient to carry out the measures to satisfy his/her needs which are important for his/her health.The Philippine Health Care Delivery Essay. Since the patient is the best judge of his/her own needs and often has clear wishes and expectations about how nursing care should be provided, he/she should, therefore, be considered as an active and responsible participant in his/her own nursing care. In order to achieve the objective of nursing interventions, that is satisfying patients’ needs and maximizing their ability to look after themselves, nurses should create a personal and constructive relationship with the patients. This requires the nurse to be sensitive, to have the capacity for insight and to provide emotional support. In addition, nursing and medical care overlaps and complements each other. Nurses therefore should support the patient and show him/her how to carry out the doctor’s orders. It is important that the nurse gives the patient advice and that he/she performs medical interventions correctly. In this regard, the nurse should possess knowledge about the patient and his/her treatment. The nurse and patient should work together towards satisfying patient’s needs and helping the patient attain the greatest possible degree of self-efficacy. In order to achieve this objective, the nurse must continuously evaluate the nursing care plan in order to maintain or improve the level of care.

Conceptual Framework

Dr. Fernando B. Duran Sr. Memorial Hospital formerly Sorsogon Provincial Hospital envisions to provide health care facility to an enlightened, health-seeking target populace combating disease, as well as promoting wellness, through adequate, timely, quality care by compassionate health care workers.

The human resources as well as the physical resources of the hospital are very vital in the healthcare delivery. Thus, this study conceptualized that the healthcare delivery system of the hospital would lead to patient satisfaction in terms of general satisfaction, technical quality, interpersonal aspects, communication, financial aspects, time spent with doctor, accessibility.

Factors which may influence the patient satisfaction such as patient-related factors which include, interaction with the staff, staff patient communication (clear explaining by staff on the procedure and care), care and concern shown by the doctor, doctors-patients ratio, nurses-patients ratio, knowledge and skill of the staff, and the time spend by doctor to attend to the patient.

The system-related factors which comprises of clinical team compassion and willingness to help, care condition, referrals, continuity of care, availability of care facility, food service, and cleanliness of the entire hospital. Base from the results of the study recommendations will be utilize to have Quality Management Program for Hospital services at Dr. Fernando B. Duran Sr. Memorial Hospital. The Philippine Health Care Delivery Essay.

Analytical Framework

The study will determined the patient satisfaction of the health care delivery of Dr. Fenrnado B. Duran Sr. Memorial Hospital. Using a validation questionnaire checklist, the data will be gathered, tabulated and analyzed in order to determine the profile of the respondents along age, sex, socio-economic (monthly family income), and educational attainment. An appropriate statistical treatment will be used to test the research hypothesis at 0.05 level of significance that there is a significant difference in the demographic profile of the patients with their level of satisfaction. From the analysis and interpretation of the data provided by the respondents, quality management programs will me proposed to have satisfied patients as healthcare delivered by the said hospital.

HEALTH CARE DELIVERY

The following terms used in this study are defined conceptually and operationally:

Drugs. These are substances that have a curative effect when ingested or introduced into the body. In this study, this refers to the substances or other preparation used for the treatment or prevention of disease usually prescribed by the health professionals for the treatment or prevention of disease.

Equipment. This term refers to set of tools, devices, kit, etc., assembled for a specific purpose. In this study this refers to machine uses in the hospital such as ECG machine, BP apparatus, Suction apparatus, Ambu bag, Nebulizer, Oxygen gauge, etc. use to deliver the health care services of the hospital

Facility. These are thing created to serve a particular function (www.thefreedictionary.com/facility). In this study, this term refers to the building and its amenities such as water and lights to serve the delivery of health services to the patients.

Factors. This is a Latin word which means “who/which acts” (en.wikipedia.org/wiki/Factor). In this study, this refers to the facilities, services, drugs, medicine, supplies, equipment and the interpersonal relationship of the health professionals to the patients. The Philippine Health Care Delivery Essay.

Health Care Service Delivery. This is the network of health facilities and personnel which carries out the task of rendering health care to the people as a complex set of organizations interacting to provide an array of health services (www.freewebs.com/…/…). In this study, this refers to the transferring of the healthcare service to the patient in the province of Sorsogon.

Health Care Service. This refers to the complete network of agencies, facilities, and all providers of health care in a specified geographic area. (medical dictionary.thefreedictionary.com/health+care+system). In this study, this refers to the healthcare services rendered by Dr. Fernando B. Duran Sr. Memorial Hospital to the people of the province of Sorsogon.

Health Care. This refers to the prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical and allied health professions (medical-dictionary.thefreedictionary.com/health+care). In this study, this refers to combating disease as well as promoting wellness, through adequate, timely, quality care by compassionate health care workers.

Health Care Delivery. This refers to the process by which the prevention, treatment, and management of illness and the preservation of mental and physical well-being is offered by the medical and allied health professions (medical-dictionary.thefreedictionary.com). In this study, it refers to the avoidance, action, and administration of illness and protection of mental and physical well-being through the health services by the health professionals.

Hospital. This refers to the health care institution that provides patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays (en.wikipedia.org/wiki/Hospital). In this study, it refers to Dr. Fernando B. Duran Sr. Memorial Hospital.

Interpersonal Relationship. This refers to the association between two or more people that may range from brief to continuing bond (en.wikipedia.org/wiki/Interpersonal_relationship). In this study, it refers to the connection between the health professionals and patients to meet the common objectives that is to treat and prevent diseases.

Level of Satisfaction. This refers to the stage of approval when comparing service or product’s performance with the personal expectations(www.businessdictionary.com/definition/satisfaction.html#ixzz25fCBSAIe). In this study, it refers to the point where in patients are pleased due to the service rendered by the health professional based on his/her expectations to treat or prevent diseases.

Level of Patient Satisfaction. This refers to the stage of approval when comparing service or product’s performance with the patients expectations In this study, it refers to the degree of congruency between the patient’s satisfaction along technical quality, interpersonal manner, communication, financial aspects, time spent with doctor and accessibility of care.

Measures. The Philippine Health Care Delivery Essay. This refers to the plans or courses of action taken to achieve a particular purpose (Webster Dictionary). In this study, it refers to the provisions for affordable medicine, facilities, and the maintenance of cleanliness of the health care facilities.

Medicines. This is the science or practice of the diagnosis, treatment, and prevention of disease in technical use often taken to exclude surgery (Merriam Dictionary). In this study, it refers to the knowledge and skills of health professionals which relates to the prevention, treat, or lessening of disease.

Patient satisfaction. Is the degree of congruency between a patient’s expectations of ideal care and his /her perception of the real care him /her receives. In this study this refers to the happiness with one’s situation in life one feels when one has fulfilled a desire, need, or expectation.

Patient-related Factors. In this study, this refers to staff interaction with patients, staff-patient communication; care concern shown by the doctors; doctor’s dominance over patients’ idea, concerns and expectations; knowledge and skills of doctors, nurses and other allied health professionals; time spent by doctor to the patients, staff appearance, care and concern shown by the doctors, nurses and other allied health professionals.

Patients. This term refers to any persons who is recipient of healthcare services, ill or injured and in need of treatment by a doctor, nurse, or other health care provider. In this study, the term refers to any person who avails of the services of Dr. Fernando B. Duran Sr. Memorial Hospital during the duration of the study.

Satisfaction. This term refers to a psychological state resulting when the emotion surrounding disconfirmed expectations is coupled with consumer’s prior feelings about the consumption experience (Webster Dictionary). In this study, this term refers to the pleasure obtained by the patient from the services of the healthcare facility and health care providers in the study.

Service. The term refers to the action of helping or doing work for someone (Merriam Dictionary). In this study, this term refers to effort done by health professionals to the patients to treat or prevent diseases.

Supplies. This term refers to the stocks of a resources from which a person or place can be provided with the necessary amount of that reserve (Webster Dictionary). In this study, this term refers to the patients’ needs which the health professional necessitated to treat or prevent diseases which exclude drugs and medicines. The Philippine Health Care Delivery Essay.

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Improving Healthcare in the Philippines with Affordable Equipment from the USA

Kary Van Arsdale, Ed.D.

Certified International Commerce Specialist and Director of International Operations, Avante Health Solutions

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There is a critical need for economical, dependable medical equipment in the Philippines. With a growing population that exceeded 100 million in 2016, the Philippines is our world's twelfth most populated country. In spite of continued growth the Philippines healthcare delivery system suffers from a variety of deficiencies.

Healthcare in the Philippines: In Need of Medical Equipment and Care Providers

In addition to a shortage of healthcare providers, there is a lack of hospital beds and medical equipment in the Philippines. In particular, there is a shortage of doctors and equipment in rural areas and poorer provinces. Of the 17 key regions of the Philippines, only 4 regions meet the minimum standards of hospital beds per 1,000 residents. And with a shortage of high quality operating room equipment in the Philippines, many patients are unable to receive the surgical care that they require.

How a Shortage of Medical Care Affects Life Expectancy in the Philippines

As a partial result of deficiencies in the healthcare delivery system, the average life expectancy for the Philippines in 2014 was 68.2, which is significantly below the world average and other East Asian countries. Men and residents of impoverished regions of the Philippines are at particular risk of premature death. In 2014, the average life expectancy of men in the Philippines was just under 65 years of age and the lifespan of residents in poorer regions of the Philippines was nearly 10 years shorter than the average life expectancy in richer areas.

The Role of Access to Hospitals and Quality Medical Equipment in the Philippines

The shortage of hospitals and surgical equipment are the primary barriers to quality healthcare in the Philippines. Half of the people who live in the Philippines reside in rural areas of the country where there are sometimes no licensed medical doctors and ill-equipped facilities with broken medical devices. Most of the best clinics and hospitals are located in larger cities such as Manila, Cebu City, Quezon City and Davao City. However, even residents of the country's capital face healthcare challenges. Staffing shortages, combined with a lack of sufficient hospital beds and poorly functioning medical equipment pose problems for city residents as well.

The Challenge of Finding Affordable Medical Equipment in the Philippines

Public and private hospitals in the Philippines face a great challenge in sourcing medical equipment that is both reliable and affordable. As a result of an extremely limited local medical device production, over 95% of medical devices are imported from other countries. Notably, many hospital owners and doctors are reluctant to buy equipment from other countries. Others worry that they will not be able to afford high quality equipment. Many doctors and clinic owners have no idea where to go to source dependable medical devices at a fair price.

How Doctors in the Philippines Find Affordable Surgical Equipment from the USA

Surgeons, doctors and hospital owners are often not aware that they can safely buy hospital equipment from trustworthy medical equipment companies in the USA. The United States leads all other countries in medical device manufacturing with approximately 43% of all medical devices being produced in the USA in 2015. Filipino hospital owners often do not realize that they can also save money by purchasing professionally refurbished medical equipment from the USA. Doctors and surgeons are delighted to find out that they can save 50% or more when they buy refurbished medical equipment. Some of the best refurbishing companies can even provide all hospital equipment needed by a facility. Purchasing from these companies leads to additional discounts and lower shipping costs.

How to Find the Best Medical Equipment Supplier for the Philippines

When choosing a medical equipment supplier, there are four key points to consider: Experience, product quality, accreditation, and references. You should select a company with decades of industry experience and registration with the USA FDA. Additionally, you should seek a company that has a long list of customers in the Philippines. Please contact us to find out how we have supplied affordable medical equipment to the Philippines since 1984. We look forward to working with you!

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. The Future of the Public's Health in the 21st Century. Washington (DC): National Academies Press (US); 2002.

The Future of the Public's Health in the 21st Century.

Hardcopy Version at National Academies Press

5 The Health Care Delivery System

For Americans to enjoy optimal health—as individuals and as a population—they must have the benefit of high-quality health care services that are effectively coordinated within a strong public health system. In considering the role of the health care sector in assuring the nation's health, the committee took as its starting point one of the recommendations of the Institute of Medicine (IOM) report Crossing the Quality Chasm (2001b: 6): “All health care organizations, professional groups, and private and public purchasers should adopt as their explicit purpose to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States.”

This chapter addresses the issues of access, managing chronic disease, neglected health care services (i.e., clinical preventive services, oral, and mental health care and substance abuse services), and the capacity of the health care delivery system to better serve the population in terms of cultural competence, quality, the workforce, financing, information technology, and emergency preparedness. In addition, the chapter discusses the responsibility of the health care system to recognize and play its appropriate role within the intersectoral public health system, particularly as it collaborates with the governmental public health agencies.

The health care sector in the United States consists of an array of clinicians, hospitals and other health care facilities, insurance plans, and purchasers of health care services, all operating in various configurations of groups, networks, and independent practices. Some are based in the public sector; others operate in the private sector as either for-profit or not-for-profit entities. The health care sector also includes regulators, some voluntary and others governmental. Although these various individuals and organizations are generally referred to collectively as “the health care delivery system,” the phrase suggests an order, integration, and accountability that do not exist. Communication, collaboration, or systems planning among these various entities is limited and is almost incidental to their operations. For convenience, however, the committee uses the common terminology of health care delivery system.

As described in Crossing the Quality Chasm (IOM, 2001b) and other literature, this health care system is faced with serious quality and cost challenges. To support the system, the United States spends more per capita on health care than any other country ($4,637 in 2000) (Reinhardt et al., 2002). In the aggregate, these per capita expenditures account for 13.2 percent of the U.S. gross domestic product, about $1.3 trillion (Levit et al., 2002). As the committee observed in Chapter 1 , American medicine and the basic and clinical research that inform its practice are generally acknowledged as the best in the world. Yet the nation's substantial health-related spending has not produced superlative health outcomes for its people. Fundamental flaws in the systems that finance, organize, and deliver health care work to undermine the organizational structure necessary to ensure the effective translation of scientific discoveries into routine patient care, and many parts of the health care delivery system are economically vulnerable. Insurance plans and providers scramble to adapt and survive in a rapidly evolving and highly competitive market; and the variations among health insurance plans—whether public or private—in eligibility, benefits, cost sharing, plan restrictions, reimbursement policies, and other attributes create confusion, inequity, and excessive administrative burdens for both providers of care and consumers.

Because of its history, structure, and particularly the highly competitive market in health services that has evolved since the collapse of health care reform efforts in the early 1990s, the health care delivery system often does not interact effectively with other components of the public health system described in this report, in particular, the governmental public health agencies. Health care's structure and incentives are technology and procedure driven and do not support time for the inquiry and reflection, communication, and external relationship building typically needed for effective disease prevention and health promotion. State health departments often have legal authority to regulate the entry of providers and purchasers of health care into the market and to set insurance reimbursement rates for public and, less often, private providers and purchasers. They may control the ability of providers to acquire desired technology and perform complex, costly procedures that are important to the hospital but increase demands on state revenues. Finally, virtually all states have the legal responsibility to monitor the quality of health services provided in the public and private sectors. Many health care providers argue that such regulation adds to their costs, and high-profile problems can create additional tensions that impede collaboration between the state public health agency and the health care delivery system.

Furthermore, when the delivery of health care through the private sector falters, the responsibility for providing some level of basic health care services to the poor and other special populations falls to governmental public health agencies as one of their essential public health services, as discussed in Chapter 1 . In many jurisdictions, this default is already occurring, consuming resources and impairing the ability of governmental public health agencies to perform other essential tasks.

Although this committee was not constituted to investigate or make recommendations regarding the serious economic and structural problems confronting the health care system in the United States, it concluded that it must examine certain issues having serious implications for the public health system's effectiveness in promoting the nation's health. Drawing heavily on the work of other IOM committees, this chapter examines the influence that health insurance exerts on access to health care and on the range of care available, as well as the shortcomings in the quality of services provided, some of the constraints on the capacity of the health care system to provide high-quality care, and the need for better collaboration within the public health system, especially among governmental public health agencies and the organizations in the personal health care delivery system.

ACCESS TO HEALTH CARE

Health care is not the only, or even the strongest, determinant of health, but it is very important. For most Americans, having health insurance— under a private plan or through a publicly financed program—is a threshold requirement for routine access to health care. “Health insurance coverage is associated with better health outcomes for adults. It is also associated with having a regular source of care and with greater and more appropriate use of health services. These factors, in turn, improve the likelihood of disease screening and early detection, the management of chronic illness, and the effective treatment of acute conditions,” IOM notes in a recent report (IOM, 2002a: 6).

Private insurance is predominantly purchased through employment-based groups and to a lesser extent through individual policies (Mills, 2002). Publicly funded insurance is provided primarily through seven government programs (see Table 5–1 ). Medicare provides coverage to 13.5 percent of the population, whereas Medicaid covers 11.2 percent of the population (Mills, 2002). Additionally, public funding supports directly delivered health care (through community health centers and other health centers qualified for Medicaid reimbursement) accessed by 11 percent of the nation's uninsured, who constitute 41 percent of patients at such health centers (Markus et al., 2002). Because the largest public programs are directed to the aged, disabled, and low-income populations, they cover a disproportionate share of the chronically ill and disabled. However, they are also enormously important for children. In early 2001, Medicaid and the State Children's Health Insurance Program (SCHIP) provided health care coverage to 23.1 percent of the children in the United States, and this figure had risen to 27.7 percent according to data from the first-quarter estimates in the National Health Interview Survey (NCHS, 2002).

TABLE 5–1

Government Health Programs.

Being uninsured, although not the only barrier to obtaining health care, is by all indications the most significant one. The fact that more than 41 million people—more than 80 percent of whom are members of working families—are uninsured is the strongest possible indictment of the nation's health care delivery system. Those without health insurance or without insurance for particular types of services face serious, sometimes insurmountable barriers to necessary and appropriate care.

Adults without health insurance are far more likely to go without health care that they believe they need than are adults with health insurance of any kind (Lurie et al., 1984, 1986; Berk and Schur, 1998; Burstin et al., 1998; Baker et al., 2000; Kasper et al., 2000; Schoen and DesRoches, 2000). Children without health insurance may be compromised in ways that will diminish their health and productivity throughout their lives.

When individuals cannot access mainstream health care services, they often seek care from the so-called safety-net providers. These providers include institutions and professionals that by mandate or mission deliver a large amount of care to uninsured and other vulnerable populations. People turn to safety-net providers for a variety of reasons: some because they lack health insurance and others because there are no other providers in the area where they live or because language and cultural differences make them uncomfortable with mainstream care. Safety-net providers are also more likely to offer outreach and enabling services (e.g., transportation and child care) to help overcome barriers that may not be directly related to the health care system itself.

In this section, the committee reviews concerns about the barriers to health care that are raised by the lack of health insurance and by threats to the nation's safety-net providers.

The Uninsured and the Underinsured

The persistently large proportion of the American population that is uninsured—about one in five working-age adults and one in seven children— is the most visible and troubling sign of the nation's failure to assure access to health care. Yet the public and many elected officials seem almost willfully ignorant of the magnitude, persistence, and implications of this problem. Surveys conducted over the past two decades show a consistent underestimation of the number of uninsured and of trends in insurance coverage over time (Blendon et al., 2001). The facts about uninsurance in America are sobering (see Box 5–1 ). By almost any metric, uninsured adults suffer worse health status and live shorter lives than insured adults (IOM, 2002a).

BOX 5–1

Findings from Coverage Matters. In its report Coverage Matters, the IOM Committee on the Consequences of Uninsurance (IOM, 2001a) found the following: Forty-two million people in the United States lacked health insurance coverage in 1999 (Mills, 2000). (more...)

Because insurance status affects access to secure and continuous care, it also affects health, leading to an estimated 18,000 premature deaths annually (IOM, 2002a). Having a regular source of care improves chances of receiving personal preventive care and screening services and improves the management of chronic disease. When risk factors, such as high blood pressure, can be identified and treated, the chances of developing conditions such as heart disease can be reduced. Similarly, if diseases can be detected and treated when they are still in their early stages, subsequent rates of morbidity and mortality can often be reduced. Without insurance, the chances of early detection and treatment of risk factors or disease are low.

However, even when the uninsured receive care, they fare less well than the insured. The IOM Committee on the Consequences of Uninsurance found that “[u]ninsured adults receive health services that are less adequate and appropriate than those received by patients who have either public or private health insurance, and they have poorer clinical outcomes and poorer overall health than do adults with private health insurance” (IOM, 2002a: 87). For example, Hadley and colleagues (1991) found that uninsured adult hospital inpatients had a significantly higher risk of dying in the hospital than their privately insured counterparts. Emergency and trauma care were also found to vary for insured and uninsured patients. Uninsured persons with traumatic injuries were less likely to be admitted to the hospital, received fewer services when admitted, and were more likely to die than insured trauma victims (Hadley et al., 1991).

For children, too, being uninsured tends to reduce access to health care and is associated with poorer health. The 1998 IOM report America's Children: Health Insurance and Access to Care found that uninsured children “are more likely to be sick as newborns, less likely to be immunized as preschoolers, less likely to receive medical treatment when they are injured, and less likely to receive treatment for illness such as acute or recurrent ear infections, asthma and tooth decay” (IOM, 1998: 3). That report emphasized that untreated health problems can affect children's physical and emotional growth, development, and overall health and well-being. Untreated ear infections, for example, can have permanent consequences of hearing loss or deafness.

Even when insured, limitations on coverage may still impede people's access to care. Many people who are counted as insured have very limited benefits and are exposed to high out-of-pocket expenses or service restrictions. Three areas in which benefits are frequently circumscribed under both public and private insurance plans are preventive services, behavioral health care (treatment of mental illness and addictive disorders), and oral health care. When offered, coverage for these services often carries limits that are unrelated to treatment needs and are stricter than those for other types of care (King, 2000). Cost-sharing requirements for these services may also be higher than those for other commonly covered services. (Additional discussion of these and other “neglected” forms of care appears later in this chapter.)

Access to care for the insured can also be affected by requirements for cost sharing and copayments. Cost sharing is an effective means to reduce the use of health care for trivial or self-limited conditions. Numerous studies, starting with the RAND Health Insurance Experiment, show that copayments also reduce the use of preventive and primary care services by the poor, although not by higher-income groups (Solanki et al., 2000). The same effects have been shown for the use of behavioral health care services (Wells et al., 2000).

As a result of the nation's increased awareness of bioterrorist threats, there are concerns about the implications of copayments and other financial barriers to health care. Cost sharing may discourage early care seeking, impeding infectious disease surveillance, delaying timely diagnosis and treatment, and posing a threat to the health of the public. The committee encourages health care policy makers in the public and private sectors to reexamine these issues in light of the concerns about bioterrorism.

This committee was not constituted to make specific recommendations about health insurance. The issues are complex, and the failures of health care reform efforts over the past 30 years testify to the difficulty of crafting a solution. However, the committee finds that both the scale of the problem and the strong evidence of adverse health effects from being uninsured or underinsured make a compelling case that the health of the American people as a whole is compromised by the absence of insurance coverage for so many. Assuring the health of the population in the twenty-first century requires finding a means to guarantee insurance coverage for every person living in this country.

Adequate population health cannot be achieved without making comprehensive and affordable health care available to every person residing in the United States. It is the responsibility of the federal government to lead a national effort to examine the options available to achieve stable health care coverage of individuals and families and to assure the implementation of plans to achieve that result.

Safety-Net Providers

Absent the availability of health insurance, the role of the safety-net provider is critically important. Increasing their numbers and assuring their viability can, to some degree, improve the availability of care. The IOM Committee on the Changing Market, Managed Care and the Future Viability of Safety Net Providers defined safety-net providers as “[t]hose providers that organize and deliver a significant level of health care and other health-related services to uninsured, Medicaid, and other vulnerable patients” (IOM, 2000a: 21). That committee further identified core safety-net providers as having two distinguishing characteristics: “(1) by legal mandate or explicitly adopted mission they maintain an ‘open door,' offering access to services to patients regardless of their ability to pay; and (2) a substantial share of their patient mix is uninsured, Medicaid, and other vulnerable patients” (IOM, 2000a: 3).

The organization and delivery of safety-net services vary widely from state to state and community to community (Baxter and Mechanic, 1997). The safety net consists of public hospital systems; academic health centers; community health centers or clinics funded by federal, state, and local governmental public health agencies (see Chapter 3 ); and local health departments themselves (although systematic data on the extent of health department services are lacking) (IOM, 2000a). A recent study of changes in the capacities and roles of local health departments as safety-net providers found, however, that more than a quarter of the health departments surveyed were the sole safety-net providers in their jurisdictions and that this was more likely to be the case in smaller jurisdictions (Keane et al., 2001).

Safety-net service providers, which include local and state governmental agencies, contribute to the public health system in multiple ways. Services provided by state and local governments often include mental health hospitals and outpatient clinics, substance abuse treatment programs, maternal and child health services, and clinics for the homeless. In addition, an estimated 1,300 public hospitals nationwide (Legnini et al., 1999) provide free care to those without insurance or resources to pay. A survey of 69 hospitals belonging to the National Association of Public Hospitals indicated that in 1997, public hospitals provided more than 23 percent of the nation's uncompensated hospital care (measured as the sum of bad debt and charity care) (IOM, 2000a). These demands can overwhelm the traditional population-oriented mission of the governmental public health agencies. Furthermore, changes in the funding streams or reimbursement policies for any of these programs or increases in demand for free or subsidized care that inevitably occur in periods of economic downturn create crises for safety-net providers, including those operated by state and local governments (see the section Collaboration with Governmental Public Health Agencies later in this chapter for additional discussion).

The IOM committee that produced the report America's Health Care Safety Net: Intact but Endangered (IOM, 2000a: 205–206) had the following findings:

Despite today's robust economy, safety net providers—especially core safety net providers—are being buffeted by the cumulative and concurrent effects of major health policy and market changes. The convergence and potentially adverse consequences of these new and powerful dynamics lead the committee to be highly concerned about the future viability of the safety net. Although safety net providers have proven to be both resilient and resourceful, the committee believes that many providers may be unable to survive the current environment. Taken alone, the growth in Medicaid managed care enrollment; the retrenchment or elimination of key direct and indirect subsidies that providers have relied upon to help finance uncompensated care; and the continued growth in the number of uninsured people would make it difficult for many safety net providers to survive. Taken together, these trends are beginning to place unparalleled strain on the health care safety net in many parts of the country. . . . The committee believes that the effects of these combined forces and dynamics demand the immediate attention of public policy officials. (IOM, 2000a: 206)

The committee fully endorses the recommendations from America's Health Care Safety Net: Intact but Endangered (IOM, 2000a), aimed at ensuring the continued viability of the health care safety net (see Box 5–2 ).

BOX 5–2

Recommendations Concerning Safety-Net Services. Federal and state policy makers should explicitly take into account and address the full impact (both intended and unintended) of changes in Medicaid policies on the viability of safety-net providers and (more...)

NEGLECTED CARE

The committee is concerned that the specific types of care that are important for population health—clinical preventive services, mental health care, treatment for substance abuse, and oral health care—are less available because of the current organization and financing of health care services. Many forms of publicly or privately purchased health insurance provide limited coverage, and sometimes no coverage, for these services.

Clinical Preventive Services

The evidence that insurance makes a difference in health outcomes is well documented for preventive, screening, and chronic disease care (IOM, 2002b). Clinical preventive services are the “medical procedures, tests or counseling that health professionals deliver in a clinical setting to prevent disease and promote health, as opposed to interventions that respond to patient symptoms or complaints” (Partnership for Prevention, 1999: 3). Such services include immunizations and screening tests, as well as counseling aimed at changing the personal health behaviors of patients long before clinical disease develops. The importance of counseling and behavioral interventions is evident, given the influence on health of factors such as tobacco, alcohol, and illicit drug use; unsafe sexual behavior; and lack of exercise and poor diets. These risk behaviors are estimated to account for more than half of all premature deaths; smoking alone contributes to one out of five deaths (McGinnis and Foege, 1993).

Coverage of clinical preventive services has increased steadily over the past decade. In 1988, about three-quarters of adults with employment-based health insurance had a benefit package that included adult physical examinations. Two years later, the proportion had risen to 90 percent (Rice et al., 1998; Kaiser Family Foundation and Health Research and Educational Trust, 2000). The type of health plan is the most important predictor of coverage (RWJF, 2001). The use of financial incentives and data-driven performance measurement strategies to improve physicians' delivery of services such as immunizations (IOM, 2002c) may account for the fact that managed care plans tend to offer the most comprehensive coverage of clinical preventive services and traditional indemnity plans tend to offer the least comprehensive coverage.

Although the trend toward inclusion of clinical preventive services is positive, such benefits are still limited in scope and are not well correlated with evidence regarding the effectiveness of individual services. The U.S. Preventive Services Task Force (USPSTF), a panel of experts convened by the U.S. Public Health Service, has endorsed a core set of clinical preventive services for asymptomatic individuals with no known risk factors. In the committee's view, this guidance to clinicians on the services that should be offered to specific patients should also inform the design of insurance plans for coverage of age-appropriate services. However, the USPSTF recommendations have had relatively little influence on the design of insurance benefits, and recommended counseling and screening services are often not covered and, consequently, not used (Partnership for Prevention, 2001) (see Box 5–3 ). As might be expected, though, adults without health insurance are the least likely to receive recommended preventive and screening services or to receive them at the recommended frequencies (Ayanian et al., 2000).

BOX 5–3

Partnership for Prevention Survey of Employer Support for Preventive Services. Counseling to address serious health risks—tobacco use, physical inactivity, risky drinking, poor nutrition—is least likely to be covered by an employer-sponsored (more...)

Having any health insurance, even without coverage for any preventive services, increases the probability that an individual will receive appropriate preventive care (Hayward et al., 1988; Woolhandler and Himmelstein, 1988; Hsia et al., 2000). Studies of the use of preventive services by Hispanics and African Americans find that health insurance is strongly associated with the increased receipt of preventive services (Solis et al., 1990; Mandelblatt et al., 1999; Zambrana et al., 1999; Wagner and Guendelman, 2000; Breen et al., 2001; O'Malley et al., 2001). However, the higher rates of uninsurance among racial and ethnic minorities contribute significantly to their reduced overall likelihood of receiving clinical preventive services and to their poorer clinical outcomes (Haas and Adler, 2001). For example, African Americans and members of other minority groups who are diagnosed with cancer are more likely to be diagnosed at advanced stages of disease than are whites (Farley and Flannery, 1989; Mandelblatt et al., 1991, 1996; Wells and Horm, 1992).

Medicare Coverage of Preventive Services

Preventive services are important for older adults, for whom they can reduce premature morbidity and mortality, help preserve function, and enhance quality of life. Unfortunately, the Medicare program was not designed with a focus on prevention, and the process for adding preventive services to the Medicare benefit package is complex and difficult. Unlike forms of treatment that are incorporated into the payment system on a relatively routine basis as they come into general use, preventive services are subject to a greater degree of scrutiny and a demand for a higher level of effectiveness, and there is no routine process for making such assessments. Box 5–4 lists the preventive services currently covered by Medicare.

BOX 5–4

Preventive Services Covered by Medicare. For individuals with Medicare, the following services are covered by Medicare Part B: Bone mass measurements for people at risk of losing bone mass

The level of use of preventive services among older adults has been relatively low (CDC, 1998). This may reflect the limited range of benefits covered by Medicare, as well as other barriers such as copayments, participants' unfamiliarity with the services, or the failure of physicians to recommend them. Cardiovascular disease and diabetes exemplify the problem. Although cardiovascular disease is the leading cause of death and diabetes is one of the most significant chronic diseases affecting Medicare beneficiaries, physicians cannot screen for lipids disorders or diabetes unless the patient agrees to pay out-of-pocket for the tests.

Medicaid Coverage of Preventive Services

Medicaid benefits vary by state in terms of both the individuals who are eligible for coverage and the actual services for which coverage is provided. The exception is preventive services for children. In 1976, the U.S. Congress added the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program to the federal Medicaid program. This entitled poor children to a comprehensive package of preventive health care and medically necessary diagnostic and treatment services. In 1996, 22.9 million children (20 percent of the nation's children) were eligible for EPSDT benefits. Given its potential to reach such a high proportion of the nation's neediest children, the program could have a very positive, widespread impact on children's health. Unfortunately, data on the program's progress are incomplete and inconsistent across the country, despite federal requirements for state reports (GAO, 2001a). However, some studies have demonstrated that EPSDT has never been fully implemented, and the percentage of children receiving preventive care through it remains low for reasons ranging from systemic state or local deficiencies (e.g., a lack of mechanisms for follow-up, issues related to managed care contracting, and confusing program requirements) to barriers at the personal level (e.g., transportation and language) (GAO, 2001a; Strasz et al., 2002). Of the 22.9 million children eligible for EPSDT in 1996, only 37 percent received a medical screening procedure through the program (Olson, 1998) (see Box 5–5 ). Additionally, data show that as many as 50 percent of children who have an EPSDT visit are identified as requiring medical attention, but if they are referred for follow-up care, only one-third to two-thirds go for their referral visit (Rosenbach and Gavin, 1998).

BOX 5–5

Children's Preventive Health Care under Medicaid. Number of eligible children. Between 1991 and 1996, the number of children eligible for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program increased by roughly 5.7 million, with (more...)

Mental Health Care

The Surgeon General's report on mental illness (DHHS, 1999) estimates that more than one in five adults are affected by mental disorders in any given year (see Box 5–6 ) and 5.4 percent of all adults have a serious mental illness. Data for children are less reliable, but the overall prevalence of mental disorders is also estimated to be about 20 percent (DHHS, 1999). Mental disorders are a major public health issue because they affect such a large proportion of the population, have implications for other health problems, and impose high costs, both financial and emotional, on affected individuals and their families. The cost to society is also high, with indirect costs from lost productivity for affected individuals and their caretakers estimated at $79 billion in 1990, the last year for which estimates are available (Rice and Miller, 1996).

BOX 5–6

Facts About Mental Illness. About 40 million people (more than one in five) ages 18 to 64 are estimated to have a single mental disorder of any severity or both a mental and an addictive disorder in a given year (Regier et al., 1993; Kessler et al., 1994). (more...)

For the most prevalent mental health disorders such as depression and anxiety, receipt of appropriate care is associated with improved functional outcomes at 2 years (Sturm et al., 1995), but the majority of individuals suffering from mental illness are not treated for their condition (DHHS, 1999). Access to care is constrained by limitations on insurance coverage that are greater than those imposed for other diseases. Annual and lifetime coverage limits are frequently less, and mental health coverage often has more hidden costs in the forms of copayments and higher deductibles (Zuvekas et al., 1998). Table 5–2 shows the distribution of sources of payment for treatment for mental health and addictive disorders in 1996. Additionally, those with no insurance all year paid nearly 60 percent of costs out-of-pocket, whereas those with some private insurance paid 40 percent of costs out-of-pocket in 1996 (Zuvekas, 2001).

TABLE 5–2

Distribution (percent) of Sources of Payment for Mental Health/Substance Abuse Treatment, by Type of Use, 1996.

Adults' use of mental health services in both the general and the specialty mental health sectors correlates highly with health insurance coverage (Cooper-Patrick et al., 1999; Wang et al., 2000; Young et al., 2001), and health insurance coverage specifically for mental health services is associated with an increased likelihood of receiving such care (Wang et al., 2000; Young et al., 2000). Recent studies have shown impressive results for treatment of depression in primary care settings (Sturm and Wells, 2000; Schoenbaum et al., 2001). The provision of such services is cost-effective and comparable to the cost-effectiveness of other common procedures. However, reimbursement policies for primary care do not support the services necessary to provide evidence-based care for depression (Wells et al., 2000; Schoenbaum et al., 2001).

Adults with either no insurance coverage or coverage that excludes or limits extended treatment of mental illness receive less appropriate care and may experience delays in receiving services until they gain public insurance (Rabinowitz et al., 2001). Adults with mental disorders are also more likely to lose health insurance coverage within a year following their diagnosis than those without a mental disorder (Sturm and Wells, 2000).

The limited and unstable nature of insurance for treatment of mental illness has several implications for governmental public health agencies because the severely mentally ill are likely to end up receiving care in publicly funded safety-net programs (Rabinowitz et al., 2001). Funding to support the public mental health system comes from reimbursements for services provided to Medicare and Medicaid participants, from federal block grants to states, and from state and local funds that support community-based programs and hospital care. Taken in the aggregate, these funding streams are neither adequate nor reliable enough to meet the needs of individuals with serious mental disorders (IOM, 2000a). As with other forms of safety-net care, the urgency of providing treatment to the severely mentally ill erodes funds available for prevention purposes.

Treatment for Substance Abuse

In the United States, more than 18 million people who use alcohol and nearly 5 million who use illicit drugs need substance abuse treatment (SAMHSA, 2001). Substance abuse, like mental illness, exacts enormous social costs across all segments of society. The total social costs of alcohol abuse alone were estimated at $177.3 billion in 1997 (Coffey et al., 2001). In that same year, $6.4 billion was spent on treatment. Total spending on drug abuse treatment equaled $5.5 billion in that year, compared with estimated social costs of drug abuse of $116.9 billion.

Most recipients (87 percent) of specialty treatment for alcohol or drug abuse receive it in outpatient settings (RWJF, 2001), but overall, less than one-fourth of those who need treatment get it. Barriers to treatment include stigma, lack of available treatment facilities, unwillingness to admit that treatment is needed, and inability to pay for care. Public sources provide more than two-thirds of the funding for alcohol and drug treatment facilities. Half of such funds come from dedicated funding at the federal, state, and local levels in the form of various block grants to state safety-net programs. Medicaid and Medicare cover 21 percent of treatment, private insurance covers 14 percent, and 10 percent is paid directly by patients as out-of-pocket costs. Another 5 percent is covered through various charitable sources.

Insurance policies held by many individuals constrain the use of substance abuse services by the exclusion of benefits for such services and by the use of annual and lifetime limits on benefits and other controls on service utilization. Between 1987 and 1997, private insurance for substance abuse services fell 0.2 percent per year on average (inflation adjusted). Over the same period, out-of-pocket payments for specific types of substance abuse treatment increased (Coffey et al., 2001). However, the high out-of-pocket costs faced by individuals who pay for their own treatment discourage many who need care from seeking it.

Oral Health Care

Like mental illness and addiction disorders, oral health has been neglected in the health care delivery system. The consequences in terms of individual and population health are significant—oral health is a matter of public health concern because it affects a large proportion of the population and is linked with overall health status (see Box 5–7 ). Oral diseases are causally related to a range of significant health problems and chronic diseases, as well as individuals' ability to succeed in school, work, and the community (DHHS, 2000b). The effects of oral diseases are cumulative and influence aspects of life as fundamental as the foods people can eat, their ability to communicate effectively, and their social acceptability. The problems in the way the health care delivery system relates to oral health include lack of dental coverage and low coverage payments, the separation of medicine and dentistry in training and practice, and the high proportion of the population that lacks any dental insurance. The committee focused on the problem of insurance and access to care.

BOX 5–7

Oral Health as a Component of Total Health. When people think about the components of good health, they often forget about the importance of good oral health. This oversight is often reflected by health insurance coverage restrictions that exclude oral (more...)

According to the Department of Health and Human Services (DHHS) Office of Health Promotion and Disease Prevention, more than 150 million Americans have limited or no dental insurance, nearly four times the number who lack insurance for medical care (cited by Allukian, 1999). As with other types of health services, insurance is a strong predictor of access to and use of dental services, and minorities and low-income populations are much less likely to have dental insurance or to receive dental care.

Individuals and families living below the poverty level experience more dental decay than higher-income groups, and their cavities are less likely to be treated (GAO, 2000). More than a third of poor children (ages 2 to 9) have one or more primary teeth with untreated decay, compared with 17.3 percent of nonpoor children (DHHS, 2000b). Mexican-American adults and children are more likely to have untreated decayed teeth than any other population group. Poor Mexican-American children ages 2 to 9 have the highest proportion of untreated decayed teeth (70.5 percent), followed by poor non-Hispanic African-American children (67.4 percent). The pattern for adults is similar (DHHS, 2000b: 63–64).

Medicare excludes coverage of routine dental care, and many state Medicaid programs do not provide dental coverage for eligible children or adults. According to a report of the Surgeon General, fewer than one in five Medicaid-covered children received a single dental visit in a recent year-long study period (DHHS, 2000b). Low-income Hispanic children and adults are less likely to be eligible for Medicaid than other groups, so even the limited Medicaid benefits are unlikely to be available to them. The forecast for major oral health problems among the nation's fastest-growing population group, Hispanics, is especially alarming.

The committee found that preventive, oral health, mental health, and substance abuse treatment services must be considered part of the comprehensive spectrum of care necessary to help assure maximum health. Therefore, the committee recommends that all public and privately funded insurance plans include age-appropriate preventive services as recommended by the U.S. Preventive Services Task Force and provide evidence-based coverage of oral health, mental health, and substance abuse treatment services.

PROBLEMS IN QUALITY OF CARE

Crossing the Quality Chasm (IOM, 2001b) examined health system failures that compromise the quality of care provided to all Americans. As noted, it is often the responsibility of state departments of health to monitor providers and levy sanctions when quality problems are identified. This adds to potential tensions with the public health system. Two particular quality problems have special significance in terms of assuring the health of the population: disparities in the quality of care provided to racial and ethnic minorities and inadequate management of chronic diseases. As the American population grows both older and more racially and ethnically diverse and as rates of chronic disease increase, important vulnerabilities in the health care delivery system are compromising individual and population health (Murray and Lopez, 1996; Hetzel and Smith, 2001).

Disparities in Health Care

A principal finding from Crossing the Quality Chasm (IOM, 2001b: 53) is that “the quality of care should not differ because of such characteristics as gender, race, age, ethnicity, income, education, disability, sexual orientation, or place of residence.” Disparities in health care are defined as “racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences and appropriateness of intervention” (IOM, 2002b: 4).

Evidence shows that racial and ethnic minorities do not receive the same quality of care afforded white Americans. These findings are consistent across a range of illnesses and health care services and remain even after adjustment for socioeconomic differences and other factors that are related to access to health care (IOM, 2002b). Furthermore, poor-quality health care is an important independent variable contributing to lower health status for minorities (IOM, 2002b). For example, racial differences in cervical cancer deaths have increased over time, despite the greater use of screening tests by minority women (Mitchell and McCormack, 1997). The lower quality of care also compounds the adverse health effects of other disadvantages faced by minorities, including lower incomes and education, less healthy living environments, and a greater likelihood of being uninsured.

As discussed in Unequal Treatment (IOM, 2002b), the factors that may produce disparities in health care include the role of bias, discrimination, and stereotyping at the individual (provider and patient), institution, and health system levels. The report found that aspects of the health care system—its organization, financing, and availability of services—may have adverse effects specifically for racial and ethnic minorities. For example, time pressures on physicians hamper their ability to accurately assess presenting symptoms, especially when cultural or language barriers are present. Nearly 14 million people in the United States are not proficient in English.

Changes in the financing and delivery of health care services, such as the emphasis on cost controls and the almost complete conversion to managed care for the delivery of services under Medicaid, may be especially problematic for racial and ethnic minorities. The disruption of traditional community-based care and the displacement of providers who are familiar with the language, culture, and values of ethnic communities create barriers to effective care (Leigh et al., 1999). In addition, segmentation of health care plans was found to play a significant role in producing poorer care for racial and ethnic minorities because they are more likely than whites to be enrolled in “lower-end” health plans (IOM, 2002b). Such plans are characterized by higher per capita resource constraints and stricter limits on covered services (Phillips et al., 2000). Fragmentation of health plans along socioeconomic lines engenders different clinical cultures, with different practice norms (Bloche, 2001).

The committee encourages the health care system and policy makers in the public and private sectors to give careful consideration to the interventions that are identified in Unequal Treatment (IOM, 2002b) and aimed at eliminating racial and ethnic disparities in health care (see Box 5–8 ).

BOX 5–8

Legal, Regulatory, and Policy Interventions to Eliminate Racial and Ethnic Disparities in Health Care. Avoid fragmentation of health plans along socioeconomic lines. Strengthen the stability of patient–provider relationships in publicly funded (more...)

Care for Chronic Conditions

Americans now live longer. A child born today can expect to live more than 75 years, and advances in medicine have also extended the life spans of earlier generations. As detailed in Chapter 1 , the result is that individuals over age 65 constitute an increasingly large proportion of the U.S. population—13 percent today, increasing to 20 percent over the next decade. Embedded in these demographic changes is a dramatic increase in the prevalence of chronic conditions. Chronic conditions, defined as illnesses that last longer than 3 months and that are not self-limiting, affect nearly half of the U.S. population. An estimated 100 million Americans have one or more chronic conditions, and that number is estimated to reach 134 million by 2020 (Pew Environmental Health Commission, 2001). Nearly half of those with a chronic illness have more than one such condition (IOM, 2001a). Additionally, disabling chronic conditions affect all age groups, but about two-thirds are found in individuals over age 65. With the projected growth in the number of people over age 65 increasing from 13 percent of the population to 20 percent, the need for care for chronic conditions will also continue to grow.

As detailed in Crossing the Quality Chasm (IOM, 2001b: 27), effective health care for chronic disease management is a collaborative process, involving the “definition of clinical problems in terms that both patients and providers understand; joint development of a care plan with goals, targets, and implementation strategies; provision of self-management training and support services; and active, sustained follow-up using visits, telephone calls, e-mail, and Web-based monitoring and decision support systems.”

The current health care system does not meet the challenge of providing clinically appropriate and cost-effective care for the chronically ill. Crossing the Quality Chasm (IOM, 2001b: 28) found that “the prevailing model of health care delivery is complicated, comprising layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful . . . a nightmare to navigate.” Although this reality is a challenge for anyone seeking care, the effects become especially damaging for those with chronic conditions. Wagner and colleagues (1996) identified five elements required to improve outcomes for chronically ill patients:

Evidence-based planned care.

Reorganization of practices to meet the needs of patients who require more time, a broad array of resources, and closer follow-up.

Systematic attention to patients' need for information and behavioral change.

Ready access to necessary clinical expertise.

Supportive information systems.

The health care delivery system as it exists today cannot deliver those elements. Recent surveys have found that less than half of U.S. patients with hypertension, depression, diabetes, and asthma are receiving appropriate treatments (Wagner et al., 2001). Delivery of high-quality care to chronically ill patients is especially challenging in a decentralized and fragmented system, characterized by small practices (AMA, 1998). Smaller practices have great difficulty in organizing the array of services and support needed to efficiently manage chronic disease. The result is poor disease management and a high level of wasted resources. As the proportion of old and very old increases, the system-wide impact in terms of cost and increased disability may well overwhelm the human and financial resources available to care for chronically ill patients.

CAPACITY OF THE HEALTH CARE SYSTEM TO SERVE THE POPULATION

The resources of the health care delivery system are not balanced well enough to provide patient-centered care, to address the complex health care demands of an aging population, to absorb normal spikes in demand for urgent care, and to manage a large-scale emergency such as that posed by a terrorist attack. The relentless focus on controlling costs over the past decade has squeezed a great deal of excess capacity out of the health care system, particularly the hospital system. It has also reduced the time that physicians spend with patients and the quality of the clinical encounter. At the same time, the design of insurance plans (in both the public and the private sectors) does not support the integrated disease management protocols needed to treat chronic disease or the data gathering and analysis needed for both disease management and population-level health. Underlying all of these problems is the absence of a national health information infrastructure to support research, clinical medicine, and population-level health.

Shortages of Health Care Professionals

The committee took special note of certain shortages of health care professionals, because these shortages are having a significant adverse effect on the quality of health care. The committee's particular concerns are the underrepresentation of racial and ethnic minorities in all health professions and the shortage of nurses, especially registered nurses (RNs) practicing in hospitals.

However, the focus on these two health care professional shortage areas does not suggest the absence of problems in other fields. Acute shortages of primary care physicians exist in many geographic areas, in certain medical specialties, and in disciplines such as pharmacy and dentistry, to name two. In addition, a growing consensus suggests that major reforms are needed in the education and training of all health professionals. To deliver the type of health care envisioned in Crossing the Quality Chasm (IOM, 2001b), health care professionals must be trained to work in teams, to utilize information technology effectively, and to develop the competencies necessary to deliver care to an increasingly diverse population. Health professions education is not currently organized to produce these results.

Underrepresentation of Racial and Ethnic Minorities

In 2000, 9 percent of physicians and 12.3 percent of RNs were from racial and ethnic minority groups (AAMC, 2000). By comparison, racial and ethnic minorities account for more than one-quarter of the nation's population. Among physicians, about 3 percent are African American, 2.2 percent are Hispanic, and 3.6 percent are Asian (AAMC, 2000). The 2000 National Sample Survey of Registered Nurses reported that 5 percent of RNs are African American, 2 percent are Hispanic, and 3.5 percent are Asian (Spratley et al., 2000). The severe underrepresentation of racial and ethnic minorities in the health professions affects access to care for minority populations, the quality of care they receive, and the level of confidence that minority patients have in the health care system.

A consistent body of research indicates that African-American and Hispanic physicians are more likely to provide services in minority and underserved communities and are more likely to treat patients who are poor, Medicaid eligible, and sicker (IOM, 2001c). Some studies indicate that, on average, minority physicians treat four to five times more minority patients than do white physicians, and studies of recent minority medical school graduates indicate that they have a greater preference to serve in minority and underserved areas. Although more research is needed to examine the impact of minority health care professionals on the level of access and quality of care, for some minority patients, having a minority physician results in better communication, greater patient satisfaction with care, and greater use of preventive services (IOM, 2002b). Although evidence has not established that increasing the numbers of minority physicians or improving cultural competence per se influences patient outcomes, existing research supports clear policies to increase the proportion of medical students drawn from minority groups.

Hospital Nursing Shortage

RNs work in a variety of settings, ranging from governmental public health agency clinics to hospitals and nursing homes. The majority, however, work in hospitals, although the proportion dropped from 68 percent in 1968 to 59 percent in 2000 (Spratley et al., 2000). Hospitals are facing shortages of RNs, in addition to shortages of pharmacists, laboratory technologists, and radiological technologists. A recent national hospital survey (AHA, 2001b) found that of 168,000 vacant positions, 126,000 were for RN positions. Hospital vacancy rates for RN positions averaged 11 percent across the country, ranging from about 10 percent to more than 20 percent in some states. Nationally, more than one in seven hospitals report a severe shortage of RNs, with more than 20 percent of RN positions vacant. In general, hospitals in rural areas report the highest percentage of vacant positions. The current shortage of RNs, particularly for hospital practice, is a matter of national concern because nursing care is critical to the operation and quality of care in hospitals (Aiken et al., 1994, 2001). In a study analyzing more than 5 million patient discharges from 799 hospitals in 11 states, Needleman and colleagues (2001) consistently found that higher RN staffing levels were associated with a 3 to 12 percent reduction in indicators—including lower rates of urinary tract infections, pneumonia, shock, and upper gastrointestinal bleeding and shorter lengths of stay—that reflect better inpatient care.

The shortage of hospital-based nurses reflects several factors, including the aging of the population, declining nursing school enrollment numbers (Sherer, 2001), the aging of the nursing workforce (the average age increased from 43.1 years in 1992 to 45.2 years in 2000) (Spratley et al., 2000), and dissatisfaction among nurses with the hospital work environment. Furthermore, nurses have available other professional opportunities, and women, who once formed the bulk of the nursing workforce, now have alternate career prospects. These trends do not appear to be a temporary, cyclical phenomenon. The aging of the population means an increase in the number of patients who require skilled care for chronic diseases and age-related conditions, but the growth in the pool of nursing professionals is not keeping pace with the growth in the patient population.

Although some of this increase is to be expected because of the overall aging of the U.S. labor force, the proportion of workers who are age 35 and older is increasing more for RNs than for all other occupations (IOM, 1996). An aging workforce may have implications for patient care if older RNs have less ability to perform certain physical tasks (HRSA, 2001). The shortage of RNs poses a serious threat to the health care delivery system, and to hospitals in particular.

Hospitals and the Capacity for Emergency Response

Hospitals contribute in various ways to assuring the health of the public, particularly by providing acute care services, educating health professionals, serving as a site for research, organizing community health promotion and disease prevention activities, and acting as safety-net providers. However, hospitals play a uniquely important role by serving as the primary source of emergency and highly specialized care such as that in intensive care units (ICUs) and centers for cardiac care and burn treatment.

Recent changes in the structure of the hospital industry, the reimbursement of hospitals by public- and private-sector insurance programs, and nursing shortages have raised questions about the ability of hospitals to carry out these roles. Although the terrorist incidents in the fall of 2001 did not directly test the ability of hospitals to respond to a medical crisis, they drew particular attention to hospitals' limited “surge capacity”—the ability to absorb a large influx of severely injured patients—in their emergency departments and specialty units.

During the 1990s, the spread of managed care practices contributed to reductions in overall hospital admissions, in the length of hospital stays, and in emergency department visits. As a result of decreasing demand for hospital services and a changing financial environment, hospitals in many parts of the country reduced the number of patient beds, eliminated certain services, or even closed (McManus, 2001). The American Hospital Association (AHA, 2001a) reports that from 1994 to 1999, the number of emergency departments in the nation decreased by 8.1 percent (see Table 5–3 ). Over the same period, medical and surgical bed capacities were reduced by 17.7 percent, ICU bed capacities were reduced by 2.8 percent, and specialty bed (including burn bed) capacities were reduced by 3.4 percent. Although these reductions may have improved the efficiencies of hospitals, they have important implications for the capacity of the health care system to respond to public health emergencies.

TABLE 5–3

Change in Hospital Capacity, 1994–1999.

Crowding in hospital emergency departments has been recognized as a nationwide problem for more than a decade (Andrulis et al., 1991; Brewster et al., 2001; McManus, 2001; Viccellio, 2001). According to the American Hospital Association (2001a), the demand for emergency department care increased by 15 percent between 1990 and 1999. In a random survey of emergency department directors in 1998 and 1999, 91 percent of the 575 respondents reported overcrowding problems (Derlet et al., 2001). The overcrowding was severe, resulting in delays in testing and treatment that compromised patient outcomes. The emergency departments of hospitals in many areas of New York City routinely operated at 100 percent capacity (Brewster et al., 2001). Patients regularly spent significant portions of their admission on gurneys in a hallway.

One consequence of this crowding is the periodic closure of emergency departments and the diversion of ambulances to other facilities. Ambulance diversions have been found to impede access to emergency services in metropolitan areas in at least 22 states (U.S. House of Representatives, 2001); at least 75 million Americans are estimated to reside in areas affected by ambulance diversions. Looking at 12 communities, Brewster and colleagues (2001) found that on average in 2001, two hospitals in Boston closed their emergency departments each day and the Cleveland Clinic emergency departments were closed to patients arriving by ambulance for an average of nearly 12 hours a day.

The increase in demand for emergency care is attributed to several factors (Brewster et al., 2001). In particular, managed care rules have changed to allow increased coverage of care provided in emergency departments . Hospitals are in better compliance with the federal Emergency Medical Treatment and Labor Act, which requires emergency departments to treat patients without regard for their ability to pay. In addition, uninsured patients are making greater use of emergency departments for nonurgent care.

Access to Primary Care

The adequacy of hospital capacity cannot be assessed without considering the system inefficiencies that characterize current insurance and care delivery arrangements. These include the demands placed on hospital emergency and outpatient departments by the uninsured and those without access to a primary care provider. The unique characteristic of primary care is the role it plays as a regular or usual source of care for patients and their families. Good primary care assures continuity for the patient across levels of care, comprehensiveness of services according to the level of health or illness, and better coordination of these services over time (Starfield, 1998).

Defining the right level of immediate and standby capacity for emergency and inpatient care depends in part on the adequacy and effectiveness of general outpatient and primary care. For example, chronic conditions like asthma and diabetes often can be managed effectively on an outpatient basis, but if the conditions are poorly managed by patients or their health care providers, emergency or inpatient care may be necessary. Billings and colleagues (1993) demonstrated strong links between hospital admission rates for such conditions and the socioeconomic and insurance status of the population in an area. For example, admission rates for asthma were 6.4 percent higher in low-income areas than in higher-income areas, with more than 70 percent of the variation explained by household income (Billings et al., 1993). Differences in disease prevalence accounted for only a small portion of the differences in hospitalization rates among low- and high-income areas.

Although Billings and colleagues did not draw conclusions about the causal pathways leading to these higher admission rates, it is likely that the contributing factors include those discussed in this chapter, such as a lack of insurance or a regular source of care and the assignment of Medicaid populations to lower-cost health plans. A follow-up analysis found the situation to be growing worse for low-income populations, as economic pressures, including lower reimbursements rates, higher practice costs, and limitations on payment for diagnostic tests, squeeze providers who have historically delivered care to academic health centers' low-income populations (Billings et al., 1996). Bindman and colleagues (1995) similarly concluded that at the community level, “there is a strong positive association between health care access and preventable hospitalization rates, suggesting that these rates can serve as an indication of access to care.” It would be a costly mistake to create additional emergency and inpatient capacity before decompressing demand by improving access to primary care services. Good primary care is associated with better birth weights (Politzer et al., 2001), lower smoking rates, less obesity, and higher rates of seat belt use (Shi et al., 1999) and is a major determinant of receiving preventive services such as blood pressure screening, clinical breast exams, and Pap smears (Bindman et al., 1996). Geographically, areas with higher primary care physician-to-population ratios experience lower total health care costs (Welch et al., 1993; Mark et al., 1996; Franks and Fiscella, 1998; Starfield and Shi, 2002). Additionally, there is evidence that primary care is associated with reduced disparities in health; areas of high income inequality that also had good primary care were less likely to report fair or poor self-rated health (Starfield, 2002). The link between the availability of primary care and better health is also supported by international evidence, which shows that nations that value primary care are likely to have lower mortality rates (all causes; all causes, premature; and cause specific), even when controlling for macro- and micro-level characteristics (e.g., gross domestic product and per capita income) (Macinko et al., in press).

The Unfulfilled Potential of Managed Care

Although Billings and colleagues focused on the preventable demands for hospital care among low-income and uninsured populations, Closing the Quality Chasm (IOM, 2001b) makes clear that the misuse of services also characterizes disease management among insured chronically ill patients.

In the early 1990s, managed care became a common feature of the health care delivery system in the United States. In theory, managed care offers the promise of a population-based approach that can emphasize regular preventive care and other services aimed at keeping a defined group as healthy as possible. These benefits are most easily achieved under a fully capitated, group practice model: patients enroll with a health care organization that is paid a certain amount per member per month to provide all necessary or indicated services to the enrolled population, and physicians are paid a monthly fee or are salaried, which separates payment from the provision of individual services. This model allows a relatively stable enrolled population for whom benefits and services can be customized; knowledge of the global budget within which care is to be delivered; and a salaried workforce in which health care providers have an incentive to keep patients healthy and reduce unnecessary use of services but also have a culture in which they monitor each others' practices and quality of care. For the patient, the model provides comprehensive care, an emphasis on prevention, and low out-of-pocket costs. Kaiser Permanente Medical Group pioneered the model more than 50 years ago on the basis of early experiences providing health care programs for employees of Kaiser industrial companies (e.g., construction, shipyards, steel mills) in the late 1930s and 1940s. 1

An important opportunity was lost when insurance companies, health plans and health providers, and the state and federal governments saw managed care primarily as a cost-containment mechanism rather than a population-based approach to delivering comprehensive and effective health care services. Reimbursement rate reductions, restrictions on care and choice of physician, and other aspects of plan management disaffected millions of Americans from the basic concept of managed care. Furthermore, rapid turnover in enrollment, particularly in Medicaid managed care, ruined economic incentives for plans to view their enrollees as a long-term investment. This loss of trust in the idea of managed care is also the loss of a great opportunity to improve quality and restrain costs. Loosely affiliated physician networks have no ability to identify their populations and develop programs specifically based on the epidemiology of the defined group. There is little ability to use data systems, shared protocols, or peer pressure to improve quality and reduce variations in health care practices.

Managed care is undergoing rapid changes, some of which are likely to further undermine its viability. Consumer demands for more choice and greater flexibility are weakening restrictions on access to providers and limitations on services. Physicians are proving more aggressive and successful in their negotiations with plans to decrease constraints, and to date, most employers have been willing to accept the higher costs that result. Employer acceptance may change in the face of double-digit insurance premium increases.

Predicting the next configuration of insurance and plan delivery systems is dangerous in a system undergoing such rapid transition. A number of major insurance plans have announced that they will begin to offer defined-contribution options. 2 This may be attractive to employers, whose liability will be defined by a specific premium amount rather than by a specified set of benefits. Consumers will be expected to shop for their own care with a medical spending account coupled with catastrophic benefits for very large expenses. This could significantly undermine the current pooling of risk and create incentives for overuse of high-technology services once a deductible for catastrophic benefits has been met. However, such plans have yet to assume a significant role in the insurance market, and few employers offer them as an alternative.

Information Technology

The development of enhanced information technology and its use in hospitals, individual provider practices, and other segments of the health care delivery system are essential for improving the quality of care. Better information technology can also support patients and family caregivers in crucial health decisions, strengthen both personal and population-based prevention efforts, and enhance participation in and coordination with public health activities. (See Chapter 3 for a discussion of the information technology needs of the governmental public health infrastructure.)

Crossing the Quality Chasm (IOM, 2001b) formulated the case that information technology is critical to the redesign of the health care system to achieve a substantial improvement in the quality of care. A strong clinical information infrastructure is a prerequisite to reengineering processes of care; coordinating patient care across providers, plans, and settings and over time; supporting the operation of multidisciplinary teams and the application of clinical support tools; and facilitating the use of performance and outcome measures for quality improvement and accountability.

From the provider perspective, better information systems and more extensive use of information technology could dramatically improve care by offering ready access to complete and accurate patient data and to a variety of information resources and tools—clinical guidelines, decision-support systems, digital prescription-writing programs, and public health data and alerts, for example—that can enhance the quality of clinical decision making. Computer-based systems for the entry of physician orders have been found to have sizable benefits in enhancing patient safety (Bates et al., 1998, 2001; Schiff et al., 2000).

Despite profound growth in clinical knowledge and medical technology, the health care delivery system has been relatively untouched by the revolution in information technology that has transformed other sectors of society and the economy. Many health care settings lack basic computer systems to provide clinical information or support clinical decision making. Even where electronic medical record systems are being implemented, most of those systems remain proprietary products of individual institutions and health plans that are based on standards of specific vendors.

The development and application of interoperable systems and secure information-sharing practices are essential to gain greater benefits from information technology. At present, only a few institutions have had the resources to build integrated information systems that meet the needs of diverse specialties and environments. Those efforts illustrate both the costs involved in developing health information systems and some of the benefits that might be expected. Kaiser Permanente, for example, is investing $2 billion in a web-based system encompassing all of the critical features needed to provide patient-centered, high-quality care: a nationwide clinical information system, a means for patients to communicate with doctors and nurses to seek medical advice, access by clinicians to clinical guidelines and other knowledge resources, and computerized order entry (Krall, 1998).

So far, however, adoption of even common and less costly information technologies has been limited. Only a small fraction of physicians offer e-mail interaction (13 percent, in a 2001 poll), a simple and convenient tool for efficient communication with their patients (Harris Interactive, 2001). Some of the documented reasons for the low level of physician–patient e-mail communication include concerns about lack of reimbursement for this type of service and concerns about confidentiality and liability. These legitimate issues are slowly being addressed in policy and practice, but there is a long way to go if this form of communication is to achieve its potential for improving interactions between patients and providers.

Enhanced information technology also promises to aid patients and the public in other ways. The Internet already offers a wealth of information and access to the most current evidence to help individuals maintain their own health and manage disease. In addition, support groups and interactive programs offer additional approaches to empower consumers. Personalized systems for comprehensive home care may improve outcomes and reduce costs. Medicare's pilot project IdeaTel—Informatics for Diabetes Education and Telemedicine—offers web-based home systems to rural and inner-city diabetics to support home monitoring, customized information, and secure links to providers and to the patients' own medical records ( www.dmi.columbia.edu/ideatel/info.html ).

Other efforts to build a personal health record (PHR) created or cocreated and controlled by the individual—and instantly available to support treatment in any setting—suggest that the PHR may provide a comprehensive, accurate, and continuous record to support health and health care across the life span (Jones et al., 1999).

A sophisticated health information infrastructure is also important to support public health monitoring and disease surveillance activities. Systems and protocols for linking health care providers and governmental public health agencies are vital for detecting emerging health threats and supporting appropriate decisions by all parties. The committee cautions, however, that systems dedicated to a single use, such as bioterrorism, will not be optimal; systems designed to be comprehensive and flexible will be of greater overall value. Ultimately, such systems should also allow the public to contribute and receive information to get the most complete database possible.

For information technology to transform the health sector as it has banking and other forms of commerce that depend on the accurate, secure exchange of large amounts of information, action must be taken at the national level to develop the National Health Information Infrastructure (NHII) (NRC, 2000). The committee endorses the call by the National Committee on Vital and Health Statistics (NCVHS) (2002) for the nation to build a twenty-first century health support system—a comprehensive, knowledge-based system capable of providing information to all who need it to make sound decisions about health. Such a system can help realize the public interest related to quality improvement in health care and to disease prevention and health promotion for the population as a whole. The rapid development and widespread implementation of an extensive set of standards for technology and information exchange among providers, governmental public health agencies, and individuals are critical.

Nevertheless, as the NCVHS report describes, neither the opportunities nor the barriers to the development of the NHII are related solely to information technology. To realize the full potential of the NHII, supportive changes in the social, economic, and legal infrastructures are also required. Policies promoting the portability and continuity of personal health information are essential. Values, practices, relationships, laws, and investment and reimbursement policies must support the creation and use of data and information systems that are consistent with the vision for the NHII (see Chapter 3 for an additional discussion and recommendation).

COLLABORATION WITH GOVERNMENTAL PUBLIC HEALTH AGENCIES

The activities and interests of the health care delivery system and the governmental public health agencies clearly overlap in certain areas, but there is relatively little collaboration between them. In addition, the authority of state health departments in quality monitoring, licensure, and rate setting can cause serious tensions between them and health care organizations. The committee discusses the extent of this separation and the particular need for better collaboration, especially in regard to assuring access to health care services, disease surveillance activities, and partnerships toward broader health promotion efforts.

The Emergence of Separate Systems

Within the public health system in the United States, collaboration between the health care sector and governmental public health agencies is generally weak. This reflects the divergence and separate development of two distinct sectors following the Second World War. Lasker and colleagues observed, “[t]he dominant, highly respected medical sector focused on individual patients, emphasizing technologically sophisticated diagnosis and treatment and biological mechanisms of disease. The considerably smaller, less well-appreciated public health sector concentrated on populations, prevention, nonbiological determinants of health, and safety-net primary care” (Lasker et al., 1997: 274). As disciplines and professional fields, medicine and public health evolved with minimal levels of interaction, and often without recognition of the lost opportunities to improve the health of individuals and the population. The health care and governmental public health sectors are also very unequal in terms of their resources, prestige, and influence on public policy.

The failure to collaborate characterizes not only the interactions between governmental public health agencies and the organizations and individuals involved in the financing and delivery of health care in the private sector but also financing within the federal government. Within the Department of Health and Human Services (DHHS), the Centers for Medicare and Medicaid Services (CMS) administer the two public insurance programs with little interaction or joint planning with agencies of the U.S. Public Health Service (PHS). Even the congressional authorizing committees for these activities are separate. For example, the Substance Abuse and Mental Health Services Administration, a PHS agency, administers block grants to states to augment funding for mental health and substance abuse programs, neither of which is well supported under Medicaid. Until recently, the Medicaid waiver program, administered by CMS on behalf of the Secretary of Health and Human Services, did not provide protection of reimbursement rates for clinics within the safety-net system. At the same time, the Health Resources and Services Administration, the PHS agency charged with funding federally qualified safety-net clinics for the poor, and the Indian Health Service were both seeking funds to support the increasing deficits of these clinics due to the growing number of uninsured individuals and the low rates of reimbursement for Medicaid clinics.

The operational separation of public health and health care financing programs mirrors the cultural differences that characterize medicine and public health. American fascination with technology, science, and medical interventions and a relatively poor understanding of the determinants of health (see Chapter 2 ) or of the workings of the governmental public health agencies also contribute to the lower status, fewer resources, and limited influence of public health. The committee views these status and resource differences as barriers to mutually respectful collaboration and to achieving the shared vision of healthy people in healthy communities. The committee also urges greater efforts on the part of the health care delivery system to meet its public health responsibilities and greater efforts on the part of governmental public health agencies to reach out to health care providers and purchasers and engage them more fully in the public health system.

The Role of Governmental Public Health Agencies as Health Care Providers

Public health departments have always differed greatly in regard to the delivery of health care services, based on the availability of such services in the community and other reasons (Moos and Miller, 1981). Some provide no personal health care services at all, whereas others provide some assortment of primary health care and safety-net services. In general, however, there has been a decrease in the number of local governmental public health agencies involved in direct service provision. In a recent survey of public health agencies, primary care or direct medical care services were the least common services provided (NACCHO, 2001). Despite this, 28 percent of local public health departments report that they are the sole safety-net providers in their communities (Keane et al., 2001).

During the 1990s, Medicaid shifted from a fee-for-service program to a managed care model. This change has been a challenge to the multiple roles of public health departments as community-based primary health care providers, safety-net providers, and providers of population-based or traditional public health services. The challenge has been both financial and organizational. First, managed care plans reimburse safety-net providers less generously than fee-for-service Medicaid providers do (under Medicaid, federally qualified health centers benefited from a federal requirement for full-cost reimbursement), and they impose administrative and service restrictions that result in reduced overall rates of compensation (IOM, 2000a). In many states and localities, these changes have decreased the revenue available to public health departments and public clinics and hospitals. In many cases, funds were no longer available for population-based essential public health services or had to be diverted to the more visibly urgent need of keeping clinics and hospitals open (CDC, 1997). The result of this interplay is that many governmental public health agencies have found themselves in a strained relationship with managed care organizations: on the one hand, encouraging their active partnership in an intersectoral public health system and, on the other, competing with them for revenues (Lumpkin et al., 1998). Second, the shift of Medicaid services to a managed care environment led some public health departments to scale down or dismantle their infrastructure for the delivery of direct medical care. The recent trend of the exit of managed care from the Medicaid market has left some people without a medical home and, in cases of changes in eligibility, has left some people uninsured. This problem may be most acute in rural areas, where public health departments are often the sole safety-net providers (Johnson and Morris, 1998).

One strategy to help lessen the negative impacts of changes in health care financing undertaken by some public health departments has been the development of formal relationships (e.g., negotiating and implementing memoranda of agreement) with local managed care organizations that provide Medicaid and, in some cases, safety-net services. Such arrangements have made possible some level of integration of health care and public health services, enhanced information exchange and continuity of care, and allowed public health departments to be reimbursed for the provision of some of the services that are covered by the benefits packages of managed care plans (Martinez and Closter, 1998). At this time, governmental public health agencies are still called on to play a role in assurance broader than that which may be compatible with their other responsibilities to population health. However, closer integration between these governmental public health agencies and the health care delivery system can help address the needs of the uninsured and underinsured. Denver Health, in Colorado, provides an intriguing example of a hybrid, integrated public–private health system (Mays et al., 2000). Denver Health is the local (county and city) public health authority, as well as a managed care organization and hospital service. Although changes in the Medicaid program continue to challenge Denver Health, it continues to balance its broad responsibilities to the public's health with its role and capacity as a large health care provider.

Disease Surveillance and Reporting

Disease surveillance and reporting provide a classic exemplar of essential collaboration between the health care system and the governmental public health agencies. The latter rely on health care providers and laboratories to supply the data that are the basis for disease surveillance. For instance, in the fall of 2001, reports from physicians who diagnosed the first cases of anthrax were essential in recognizing and responding to the bioterrorism attack.

States mandate the reporting of various infectious diseases (e.g., AIDS, hepatitis B, measles, rabies, and tuberculosis) and submit data to federal disease surveillance systems (CDC, 1999). Governmental public health agencies also depend on astute clinicians to inform them of sentinel cases of recognized diseases that represent a special threat to the public's health and of unusual cases, sometimes without a confirmed diagnosis, that may represent a newly emerging infection, such as Legionnaires' disease or West Nile virus in North America. Other types of public health surveillance activities, such as registries for cancer cases and for childhood immunizations, also depend on reporting from the health care system.

Effective surveillance requires timely, accurate, and complete reports from health care providers. In the case of infectious diseases, if all systems work effectively, the necessary information regarding the diagnosis for a patient with a reportable disease is transmitted to the state or local public health department by a physician or laboratory. For unusual or particularly serious conditions, public health officials offer guidance on treatment options and control measures and monitor the community for any additional reports of similar illness. For diseases like tuberculosis and sexually transmitted diseases, public health agencies facilitate active tracking and prophylactic treatment of persons exposed to an infected individual. Disease reporting requirements vary from state to state, although most states include diseases identified by the Centers for Disease Control and Prevention (CDC) as part of the National Notifiable Disease Reporting System.

Disease reporting is not complete, however. For diseases under national surveillance, from 6 to 90 percent of cases are reported, depending on the disease (Teutsch and Churchill, 1994; Thacker and Stroup, 1994). Incomplete reporting may reflect a lack of understanding by some health care providers of the role of the governmental public health agencies in infectious disease monitoring and control. In some instances, physicians and laboratories may be unaware of the requirement to report the occurrence of a notifiable disease or may underestimate the importance of such a requirement. The difficulty of reporting in a busy practice is also a barrier.

Notifiable disease reporting systems within public health departments with strong liaisons with the health care community are important in the detection and recognition of bioterrorism events. However, this valuable tool has not been well supported and, as noted earlier, suffers from issues of lack of timeliness and incomplete reporting, as well as complex or unclear reporting procedures and limited feedback from governmental public health agencies on how data are used (Baxter et al., 2000; Stagg Elliott, 2002). Health care delivery systems may fear that the data will be used to measure performance, and concerns about patient confidentiality can also contribute to a reluctance to report some diagnoses. New federal regulations regarding the confidentiality of medical records, required by the Health Insurance Portability and Accountability Act (P.L. 104–191) have generated enormous uncertainty and apprehension among health care providers and health systems regarding the sharing of individual clinical data.

Health care providers may also reduce their use of laboratory tests to confirm a diagnosis. This may be because of cost concerns or insurance plan restrictions or simply professional judgment that the test is unnecessary for appropriate clinical care. However, when fewer diagnostic tests are performed for self-limiting illnesses like diarrhea, there may be delays in recognizing a disease outbreak. Reduced use of laboratory testing prevents the analyses of pathogenic isolates needed for disease tracking, testing of new pathogens, and determining the levels of susceptibility to antimicrobial agents.

Other changes in the health care delivery system also raise concerns about the infectious disease surveillance system. As patterns of health care delivery change, old reporting systems are undermined, but the opportunities offered by new types of care systems and technologies have not been realized. For example, traditional patterns of reporting may be lost as health care delivery shifts from inpatient to outpatient settings. Hospital-based epidemiological reporting systems no longer capture many diagnoses now made and treated on an outpatient basis. This would not be a problem if health care systems used currently available information technologies, including electronic medical records and internal disease surveillance systems.

Better information systems that allow the rapid and continuous exchange of clinical information among health care providers and with public health agencies have the potential to improve disease surveillance as well as aid in clinical decision making while avoiding the use of unnecessary diagnostic tests. With such a system, a physician seeing an influx of patients with severe sore throats could use information on the current community prevalence of confirmed streptococcal pharyngitis and the antibiotic sensitivities of the cultured organisms to choose appropriate medications. From a public health perspective, such a system would permit continuous analysis of data from a number of clinical sites, enabling rapid recognition and response to new disease patterns in the community (see Chapter 3 for a discussion of syndrome surveillance). For example, toxic or infectious exposures could be tracked more easily if the characteristics of every patient encounter were integrated into one system and if everyone had unimpeded access to systems of care that could generate such data.

A CDC-funded project of the Massachusetts Department of Public Health and the Harvard Vanguard Medical Associates (a large multi-specialty group) offers a glimpse of the benefits to be gained through collaboration between health care delivery systems and governmental public health agencies and specifically through the effective use of medical information systems (Lazarus et al., 2002). The Harvard Vanguard electronic medical system is queried each night for specific diagnoses assigned during the preceding day in the course of routine care. Diagnoses of interest are grouped into syndromes, and rates of new episodes are computed for all of eastern Massachusetts and each census tract. Expected numbers of new episodes are obtained from a generalized linear mixed model that uses data from 1996 to 1999. These expected numbers allow estimates of the probability of observing specific numbers of cases, either overall or in specific census tracts, and the rapid identification of an unusual cluster of events. The value of this type of real-time monitoring of unusual disease outbreaks is obvious for early identification of bioterrorism attacks as well as for improvements in clinical care and population health.

Sentinel Surveillance

Reports of sentinel events have proved useful for the monitoring of many diseases, but such reports may be serendipitous and generated because of close clustering, unusual morbidity and mortality, novel clinical features, or the chance availability of medical expertise. Sentinel networks that specifically link groups of participating health care providers or health care delivery systems to a central data-receiving and -processing center have been particularly helpful in monitoring specific infections or designated classes of infections. Examples of such networks are the National Nosocomial Infections Surveillance system and the National Molecular Subtyping Network for Foodborne Disease Surveillance (PulseNet). More recently, CDC has implemented a strategy directed to the identification of emerging infectious diseases in collaboration with many public health partners. The Emerging Infections Program (EIP) is a collaboration among CDC, state public health departments, and other public health partners for the purpose of conducting population-based surveillance and research on infectious diseases. At present, nine states (California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee) act as a national resource for the surveillance, prevention, and control of emerging infectious diseases (CDC, 2002). The EIP sites have performed investigations of meningococcal and streptococcal diseases and have established surveillance for unexplained deaths and severe illnesses as an attempt to identify diseases and infectious agents, known and unknown, that can lead to severe illness or death (CDC, 2002).

Preparing Health Care Professionals

Academic health centers (AHCs) serve as a critical interface with governmental public health agencies in several ways. First, as noted earlier, AHCs are an important part of the safety-net system in most urban areas. Second, they are the principal providers of specialized services and serve as regional referral centers for smaller towns or cities and rural areas. Both in normal periods and especially when confronted with either natural disasters or terrorist events, the specialized care units are an essential resource for public health. Moreover, they are also primary loci for research and training. AHCs also have a unique and special set of values that they bring to health care that transcend the discrete functions they perform.

The environment in which AHCs operate has changed substantially over the past decade. The advent of managed care plans that seek services from the lowest-cost appropriate provider and changes in federal (Medicare) reimbursement policies that reduced subsidies for costs associated with AHCs' missions in education, research, and patient care have created considerable pressure on academic institutions to increase efficiency and control costs. At the same time, advances in information technology and the explosion of knowledge from biomedical research have enormous implications for the role of AHCs in the health care system and in population health. Scientific and technological advances will permit clinical care to intervene early in a disease process by identifying and modifying personal risk. The burgeoning knowledge base will require different educational approaches to use the continuously expanding evidence base, with an emphasis on continuing education and lifetime learning.

These changes may result in a broader mission for AHCs that explicitly includes improving the public's health, generating and disseminating knowledge, advancing e-health approaches (i.e., that utilize the Internet and electronic communication technologies), providing education to current health professionals, providing community service and outreach, and delivering care that has the attributes necessary for practice. The ability of academic medicine to evolve into a broader mission will depend on changes in payment systems that may be difficult to achieve and on internal changes within AHCs that may be equally difficult.

Governmental public health agencies may also play an important role in preventive medicine and public health education. Health departments, for example, provide unique venues for the training of nurses, physicians, and other health care professionals in the basics of community-based health care and gain an understanding of population-level approaches to health improvement. Furthermore, public health students and preventive medicine residents gain practical experience in health department rotations, where they participate in program planning and evaluation and learn about assessing a community's health care needs and implementing strategies that change the conditions for health.

COLLABORATION WITH OTHER PUBLIC HEALTH SYSTEM ACTORS

In addition to the linkages between the health care delivery system and governmental public health agencies, health care providers also interface with other actors in the public health system, such as communities, the media, and businesses and employers.

Relationships between the health care sector—hospitals, community health centers, and other health care providers—and the community are not new and have gained increased recognition for the value they bring to health care operations, their potential for enhancing provider accountability (VHA and HRET, 2000), the knowledge and empowerment they help to create in communities, and their potential for promoting health.

The recent trend among universities to assess their level of involvement in their communities and to develop programs focused on “service learning,” and such public service oriented academic work includes AHCs. Calleson and colleagues (2002) surveyed the executives and staff of eight AHCs around the country and found that community–campus partnerships can strengthen the traditional mission of AHCs. The involvement of AHCs in the communities is also likely to increase in the coming years. The AHCs surveyed listed several factors that facilitated the development of relationships with communities and community organizations, including the request of the communities themselves and the growing population health orientation of the health care sector. Furthermore, non-academic community health centers also frequently have close ties to their communities, collaborating to assess local health needs, providing needed services, and supporting community efforts with research expertise and technical assistance in planning and evaluation. Many hospitals participate in broad community-based efforts to achieve some of the conditions necessary for health, for instance, collaborating with community development corporations to contribute financial, human, and technical resources (U.S. Department of Housing and Urban Development, 2002). Montefiore Medical Center in the Bronx, New York, for example, has partnered with a local nonprofit organization to develop low- and moderate-income housing and to establish a neighborhood kindergarten (Seedco and N-PAC, 2002). Additionally, Montefiore Medical Center partners with local high schools to develop health care professions education programs intended to create new career options and improve the likelihood inner-city youth will stay in school (Montefiore Medical Center, 2001). Hospitals are also employers, and in the case of two Lawndale, Illinois, hospitals, collaboration with the local development corporation and other neighborhood organizations in 1999 made affordable local housing available to employees, helping to facilitate community development (University of Illinois, 1999). In Providence, Rhode Island, a community partnership of nonprofit and independent hospitals and colleges works to improve children's quality of life by providing school-based health services, innovative and enhanced education through teacher and staff training, and support to improve home environments through housing advocacy (Health & Education Leadership for Providence, 2001; Providence Public School District, 2002).

Many hospitals and health care systems have seen the value of going beyond the needs of the individuals who enter the health care system to engage in broader community health action, even within the constraints of the current environment. The National Community Care Network Demonstration Program, sponsored by the Hospital Research and Education Trust (HRET), reports on hospitals across the country that are supporting activities beyond the delivery of medical care to improve health status and quality of life in local communities. Some of the motivation comes from the increasing pressure on nonprofit hospitals to justify their tax-exempt status through the provision of services that benefit the community, largely the provision of charity care; yet, many are seeing that investments in community health improvement are greater in value than the provision of medical care for preventable diseases (Barnett and Torres, 2001).

Vignettes drawn from the experience of American Hospital Association NOVA Award recipients illustrate the importance of investing in overall community health (AHA, 2002). For example, in 1994, Parkland Health and Hospital System in Dallas noted that injury rates in the community were three times the national average and that trauma admissions had jumped 38 percent in one year (53 percent of that care is uncompensated). As a result, the organization decided to convene the county's leading trauma care providers, police, and civic groups to investigate and solve the problem. With start-up funding from a local foundation, its own fundraising, and annual corporate sponsorships ranging from $35,000 to $150,000 from local hospitals and businesses, the coalition launched a Safe Communities initiative with a 52-member community advisory panel. Coalition members decided to tackle, in order, injuries caused by car accidents, violence, falls, and burns, through 11 initiatives involving more than 80 community organizations and agencies. Over a 2-week period, there was a 13 percent reduction in trauma admissions from car crashes due to a public awareness campaign and police initiative (AHA, 2002).

A 1998 finalist for the Foster G. McGaw Prize for Excellence in Community Service co-sponsored by AHA, the Franklin Community Health Network (FCHN) in Farmington, Maine, took the lead in developing a coalition and providing seed money to start a Rural Schools Equity Campaign (AHA, 2002). With high levels of youth involvement, and media cooperation, the campaign led to the legislative reformulation of property taxes to increase funding for rural schools in FCHN's service area by $1.3 million. In a further example, the Crozer-Keystone Health System that serves Chester, Pennsylvania, was declared a distressed municipality by the state in 1994. Although at the time the health system had been increasing its health care outreach programs, it realized it had to look at “root causes.” As the largest employer in Chester, the system organized Community Connections, a mosaic of health, economic, and social programs and services developed in partnership with 20 other organizations, a local university, and governmental agencies. Programs included attracting other businesses to Chester, setting up a business incubator building, and colocating multiple health and social programs to facilitate “one-stop shopping.” The effort has had a major stabilizing effect on Chester, and although overall health indicators are still behind state averages for chronic diseases, they are improving. Immunization rates have improved from 36 to 99 percent, and teen pregnancy is down to 31 per 1,000 from 44 per 1,000.

Under the guidance of an external review panel, HRET and the Voluntary Hospital Association of America (VHA) Health Foundation reviewed the experiences of recipients of the Foster G. McGaw Prize 3 from 1986 to 1998 and VHA Community Health Improvement Leadership Awards from 1996 to 1998. Fifteen of 20 winners participated in a study, which included a self-assessment of changes since the time of the award and in-depth interviews with chief executive officers, trustees, and those leading the initiative. Although this survey serves only as an illustration of what may be possible, several elements appeared supportive of a sustained commitment to efforts at community health improvement. These included

Committing leadership at multiple levels through the top leadership to sustain changes;
Developing community partnerships to develop champions outside the organization;
Protecting funding and leadership of community health initiatives while integrating community health values into the culture of the parent organization;
Linking community work with clinical work (mission alignment);
Building an evidence base through evaluation and ongoing measurement of community health indicators; and
Exploring external revenue streams and advocating for changes in current health care financing and funding for such efforts (VHA Health Foundation and HRET, 2000).

Boufford (1999) has suggested a Community Health Improvement Strategy that identifies a number of steps that provider organizations can take in such community-based efforts (see Box 5–9 ). However, payment systems are critical to encourage and sustain these network initiatives, and current reimbursement policies in public and private insurance are not designed to support population-focused care in a noncapitated system.

BOX 5–9

Community Health Improvement Strategy. Identify a defined population (“community”) and develop links to that community Assess health status and need, and adjust the volume and types of services provided to respond to the health needs of (more...)

The health care sector can also develop linkages with the media to help ensure the accuracy of health information, communicate risk, and facilitate the public understanding of health care. For example, health care organizations may use the media to disseminate health care information to their market areas, as demonstrated by the Minneapolis Allina Health System in its collaboration with a local television station and a health care news provider (Rees, 1999). Additionally, the media may be a powerful tool for familiarizing the public with health and health care issues and a conduit for raising important questions, stimulating public interest, or even influencing the public's health behaviors. For example, the popular prime time television show ER frequently serves as a platform for health information, with episodes exploring topics such as childhood immunizations, contraception, and violence (Brodie et al., 2001; also see Chapter 7 ).

Businesses and employers most commonly interface with the health care sector in purchasing and designing employee health benefits, with goals such as the inclusion of comprehensive preventive health care services. However, there are examples of wide-reaching business–health care linkages, such as the efforts to ensure quality of care and enhanced consumer choice undertaken by the Pacific Business Group on Health (see Chapter 6 ). Chapter 4 provides additional examples of fruitful community partnerships involving the health care sector.

IMPLICATIONS OF GROWING HEALTH CARE COSTS

As the committee has noted, health-related (mostly health care-related) spending in the United States amounted to $1.3 trillion in 2000, about 13.2 percent of the gross domestic product (Levit et al., 2002). After a period of stability in the mid-1990s, health care costs are again rising because of several factors (Heffler et al., 2002). Prescription drug spending, in particular, has increased sharply, and increased by 17.3 percent from 1999 to 2000 (HCFA, 2002). This increase comes from the growth of the older population and the proportion of the overall population with chronic conditions, along with the introduction of new and more expensive drugs, many of which are used to treat chronic conditions. In addition, spending for hospital services increased by 5.1 percent between 1999 and 2000, reaching $412 billion, and the cost of nursing home and home health care increased by 3.3 percent (Levit et al., 2002). However, the increase in health spending also reflects the success of federal and state efforts to enroll more low-income children in Medicaid and the State Children's Health Insurance Program, increased enrollment in Medicare as the population ages, and some erosion of unpopular cost-control features imposed by managed care plans.

With the economic downturn in 2001, the growth in health care spending creates added financial burdens for everyone, including individuals seeking care or insurance coverage, employers offering health insurance benefits, and governments at the federal, state, and local levels managing publicly funded insurance programs (Fronstin, 2002; Trude et al., 2002). Substantial increases in health insurance premiums are a clear indication of these economic stresses. For example, the California Public Employees' Retirement System, which is the nation's second largest public purchaser of employee health benefits, recently announced that health insurance premiums would increase by 25 percent (Connoly, 2002). States are experiencing serious pressures from growth in Medicaid spending, which increased by about 13 percent from 2001 to 2002, following a 10.6 percent increase in 2001 (NASBO, 2002a). With revenues increasing by only about 5 percent in the same period, Medicaid now accounts for more than 20 percent of total state spending (NASBO, 2002b).

The growing cost of health care has obvious implications for the nation's readiness to address the problems discussed in this chapter. Providing coverage to the uninsured, improving coverage for certain types of care, strengthening the emergency response and surge capacity in the hospital sector, and investing in information systems that can improve the quality of individual care and population-based disease surveillance will all require significant new resources from the public and private sectors. Although these steps can be expected to improve the nation's health and may even reduce costs over time, the initial investment will be substantial. The committee is concerned that with the escalation of expenditures, going in large measure toward maintaining current services, it will be difficult to identify the necessary public- and private-sector resources that will be needed for new activities.

The committee recommends that bold, large-scale demonstrations be funded by the federal government and other major investors in health care to test radical new approaches to increase the efficiency and effectiveness of health care financing and delivery systems. The experiments should effectively link delivery systems with other components of the public health system and focus on improving population health while eliminating disparities. The demonstrations should be supported by adequate resources to enable innovative ideas to be fairly tested.

CONCLUDING OBSERVATIONS

This chapter has outlined the main areas in which the health care delivery system and the governmental public health agencies interface. These areas include the regulatory and quality monitoring functions performed by governmental agencies, disease surveillance and reporting by health care providers, and the provision of safety-net services. Although assurance is a core function of public health, governmental public health agencies often do more than assure that people can access health care services; public health departments may become providers of last resort in areas where no other services are available for low-income, uninsured populations and when managed care services to Medicaid and uninsured populations are discontinued. These circumstances force public health departments to provide personal health care services instead of using their resources and population-level approaches to guide and support community efforts to change the conditions for health. Closer collaboration and integration between governmental public health agencies and the health care delivery system may enhance the capacities of both to improve population health and may support the efforts of other public health system actors.

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Group Health of Puget Sound and the Health Insurance Plan of New York were also pioneers in group model health maintenance organizations.

Defined-contribution health care benefits are a new way for employers to provide health care coverage to their employees, while no longer acting as brokers between employees and insurance companies contracted to provide benefits. An employer may choose from several different ways to put money into a health benefits account for each employee and offer the employee a menu of coverage options, with different funding levels and employee financial responsibility for each.

The Foster G. McGaw Prize for Excellence in Community Service is awarded by the American Hospital Association to recognize hospitals that have distinguished themselves through efforts to improve the health and well-being of everyone in their communities.

Cite this Page Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. The Future of the Public's Health in the 21st Century. Washington (DC): National Academies Press (US); 2002. 5, The Health Care Delivery System.
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[OPINION] 5 thoughts about the Philippine healthcare system

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This is AI generated summarization, which may have errors. For context, always refer to the full article.

[OPINION] 5 thoughts about the Philippine healthcare system

A two-week confinement recently and a longer one last year for COVID-19 got me thinking about the Philippine healthcare system and hospitalization costs, in particular. As I lay in bed waiting to heal, I had five thoughts about the medical system.

One, it is expensive to get sick in this country and to be hospitalized – too expensive for many Filipinos of lower middle income and below.
Two, doctors have their own specializations and coordination of multiple doctors with one patient is often not seamless and even fragmented.
Three, nurses and nursing assistants are underpaid.
Four, nurses are well trained but nursing assistants could receive better training.
Five, the pricing of medicines based on the hospital room used is wrong.

The five thoughts discussed

One, confinement in hospital can add up in cost very quickly especially if lab work, procedures and operations need to be done. Such a situation can put many Filipino families in a huge financial dilemma.

Membership in HMOs (Health Maintenance Organizations) is advised to help manage the extraordinary cost that goes with hospitalization but this stops after 65 years of age, a time when seniors will need more health care, not less. PhilHealth is useful but limited. The senior discount was helpful in my case. Yet after all these deductions, the out-of-pocket was still substantial. Personal debt is resorted to and if through informal sources, could carry with it high if not exorbitant rates of interest. Many hospitals offer a deferred payment plan but this can affect a hospital’s cash flow position which could have an impact on its medical service.

In the last year, two individuals from working class families known to me have seen family members pass away from disease that crept up on them (non-COVID-19) that required hospital care but which they kept ignoring or postponing because of the cost until it was too late. No health insurance, no savings in their cases, and despite help from a call to friends, it was too late. This is a story oft-repeated among those with lesser means in life.

Two, in my confinement for over a month with COVID-19 in 2021, a number of doctor-specialists were assigned to me upon my check-in in the emergency unit – a cardiologist, a pulmonologist, an infectious disease specialist, on top of my nephrologist, endocrinologist, and neurologist, the last three from my previous history of diabetes, renal failure, and a stroke. I got the sense that they were not coordinating on my treatment given the conflicting instructions given to nurses on medications and procedures. I found myself having to call doctors to clarify these things before things were clarified and/or changed.

In a recent two-week confinement (non-COVID-19), the experience had thankfully improved for me. The 7 doctors – four from my COVID-19 confinement previously – were speaking to each other and sharing updates. A lead doctor – in this case the infectious disease specialist – set up a Viber group so that the 7 of them could share notes on a daily basis. This helped the nurses explain medications and procedures more clearly. The only issue was the process of getting clearance from each of them when it became clear that my blood infection had been arrested. Chasing all seven doctors to get their clearances for my discharge took numerous follow up calls by my wife (mostly) and myself until it was finally done. The longer wait, however, added an additional day in hospital including a long wait for accounting to itemize the final bill for payment. The additional waiting time comes with its concomitant costs.

Three, from my conversations with nurses and nursing assistants (caregivers), I came to find out that they are grossly underpaid. Nurses in the private hospital were paid a monthly salary of P22,000. They told me that nurses in government hospitals had a higher monthly salary of P36,000. When asked why they did not transfer, the answer was generally one of two: Government hospital working conditions were more difficult (more patients to look after per shift, little time to rest, poorer facilities), or the private hospital was JCI-accredited and this meant that nurses there had a better chance of working abroad (US, Canada, UK, Australia) when applying for overseas placement. A number of nurses had worked previously in Saudi Arabia and had experienced better pay and working conditions but were now looking for an immigration opportunity for a more permanent move.

Nursing assistants (caregivers) in this private hospital were in an even more precarious position. Their monthly salary was P12,000 and they were on 6-month contracts with no security of tenure.

In another private hospital, a dialysis nurse there who had a monthly salary of P14,000 said she chose to return after a two-year stint in Saudi Arabia to be with an 8-year old daughter. She has a second job for a second income to help her husband and family.

There was a also pattern I observed which I hope is not the normal thinking. In my hospital stay, I met two nurses who had been community nurses but who shifted to hospitals because of the better pay. Then, I met nurses in that private hospital looking to migrate in search of better opportunities.

This is an often-heard refrain: Nurses looking or actually migrating to greener pastures. In my dialysis center, four dialysis nurses have migrated to Canada, the US and Germany in the last two years. These are highly trained medical professionals that we lose to other countries. And there are more are in that pipeline.

Four, nurses are well trained but nursing assistants could receive better training. This is the difference between a four-year degree and a short certificate course. Caregivers take a short course TESDA (Technical Education And Skills Development Authority) training with certification but it perhaps could benefit from more hands-on medical training.

Five, the pricing of medicines based on the hospital room used is wrong. In my first hospital stay, all the medicines were given by the hospital. I was not allowed to use my available supply of maintenance medication including insulin. The price differential between the drugs I purchased myself versus the hospital-administered medication was higher by a factor of 2-4 adding significantly to my hospital bill.

A business school colleague now managing a hospital consulting group revealed that private hospitals follow differential pricing on services and supplies charged based on the room contracted. In the case of medicines which has a retail price in the publicly available drug stores and pharmacies, this pricing differential is akin to price-gouging.

What to do?

There is a lot that needs to be done with regard to our healthcare system. As a senior, I am increasingly having to use it more frequently, so I begin to see certain inefficiencies in the system that can lead to high healthcare and hospitalization costs.

The Universal Health Care Act (2019) was enacted “to realize universal coverage through a systematic approach and clear delineation of roles of key stakeholders towards better performance of key agencies and stakeholders in the healthcare system.”

Alvln Manalansan, a non-resident fellow of Stratbase CADR Institute and a convenor of CitizenWatch Philippines wrote an article in March 2021 whose title summed up the cause: “Urgency to transform fragmented health system.”

“Like any other health care system,” he wrote, “the vision of the UHC Act is remarkably outstanding, however, the main challenge is in its implementation. If the UHC Law is fully implemented, it will provide equitable access to quality and affordable healthcare services while protecting against financial risk for every Filipino. However, as frequently mentioned by the DOH, the law cannot be implemented instantly, but only progressively, mainly due to its high resource requirements at all levels.”

What can be done to bring more efficiency into the health care system?

We could start by appointing a secretary of health well-respected by the medical and health care establishment with knowledge ranging from community health care to hospital care, from pre-natal and maternal health care to gerontology (care for the elderly), and everything in between. The secretary need not be expert in all areas; he or she just needs to know the leading players in the each field and can assemble a first-rate team to look after and manage the system’s different parts.

In his column for the Philippine Daily Inquirer, business consultant Peter Wallace wrote , “In 2020, the country’s total health expenditure reached P1 trillion, 5.6% of GDP in that year. So, it should be the most important department in government, with the most competent, most highly experienced leader that can be found. From what we’ve heard, there are such leaders. The President only has to choose which one. Now.”

Let’s assemble the finest group of health economists, business managers, and public policy analysts to sit with the Department of Health leadership team and key medical practitioners to take apart the Universal Health Care Act to see how the entire system can be more integrated, more seamless, more efficient, and less costly to all Filipinos. Studying how certain countries have set up their national health programs (I.e. Canada, Europe) would be instructive. Congress has created an Education Commission II to overhaul the basic education system to improve system performance; a similar Health Commission should be considered.

A consolidation of small private hospitals with larger hospital groups will bring needed investment into this sub-sector, help modernize it, and generate the economies of scale that could drive costs down.

Health insurance should be made available to all with substantial benefits and a variant for senior citizens should be designed and implemented, including home care for the elderly and even hospice care for those nearing death. Incentives and tax breaks should be available to private health insurers providing health insurance and HMO coverage to seniors above age 65.

Most important, investment by Government in community health and preventive medicine should be increased. As in many cases in other fields, investing in prevention minimizes future risk and is less costly than clinical care.

Lastly, let’s pay our nurses and non-doctor medical personnel better wages. We need to provide better economic benefits to encourage them to stay in the country. – Rappler.com

Juan Miguel Luz was former Dean and Head of the School of Development Management at the Asian Institute of Management, and former Undersecretary, Department of Education.

Please abide by Rappler's commenting guidelines .

Totally agree with the writer. I am one of the Filipino nurses who migrated to the USA, 50 years ago. It saddens me that the conditions Mr. Luz describes was true back then, and that the system has not improved. Granted, the healthcare system is a complicated one. But all the suggestions for improvement that Mr. Luz proposes have been known even 50 years ago. The problem has always been in the implementation. That phase seems to be the thorniest of all phases. We have excellent thinkers, but the implementation phase is plagued by lack of resources, politics, lack of will, etc. Good luck to the next generation. May they get better at solving this great social need.

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