Jones R, McConville J, Mason D, Macpherson L, Naven L, McEwen J. . Employer acceptance may change in the face of double-digit insurance premium increases. 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). Health care delivery systems differ depend- ing on the arrangement of these components. Health insurance coverage is associated with better health outcomes for adults. Barriers to treatment include stigma, lack of available treatment facilities, unwillingness to admit that treatment is needed, and inability to pay for care. 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. Medicare's pilot project IdeaTelInformatics for Diabetes Education and Telemedicineoffers 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). For these reasons, oral health must recognized as an important component of assuring individual and population health. What are the two main objectives of a healthcare delivery system? Quality health care can be defined in many ways but there is growing acknowledgement that quality health services should be: Effective - providing evidence-based healthcare services to those who need them; Safe - avoiding harm to people for whom the care is intended; and 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). 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). Andrulis DP, Kellermann A, Hintz EA, Hackman BB, Weslowski VB. 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. 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 indicatorsincluding lower rates of urinary tract infections, pneumonia, shock, and upper gastrointestinal bleeding and shorter lengths of staythat reflect better inpatient care. Consumer demands for more choice and greater flexibility are weakening restrictions on access to providers and limitations on services. Preventive Services Covered by Medicare. Breen N, Wagener DK, Brown ML, Davis WW, Ballard-Barbash R. 2001. This reflects the divergence and separate development of two distinct sectors following the Second World War. The uninsured were less likely to receive health care services, even for serious conditions. 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). If information is important enough that it is needed to manage the patient or the system, then it must be acquired as part of the . health management associates accountable care institute 180 north lasalle, suite 2305, chicago, illinois 60601 telephone: 312.641.5007 fax: 312.641.6678 www.healthmanagement.com pat terrell, executive director terry conway, md, director of clinical practice doug elwell, director of finance art jones, md, director of finance greg vachon, md, director of clinical practice 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. 4 Components of the United State health care delivery system. 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). 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). Medicare provides coverage to 13.5 percent of the population, whereas Medicaid covers 11.2 percent of the population (Mills, 2002). The evidence that insurance makes a difference in health outcomes is well documented for preventive, screening, and chronic disease care (IOM, 2002b). 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). 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. 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). Those efforts illustrate both the costs involved in developing health information systems and some of the benefits that might be expected. This committee was not constituted to make specific recommendations about health insurance. Without insurance, the chances of early detection and treatment of risk factors or disease are low. IHS (2002a, 2002b). Consumers will be expected to shop for their own care with a medical spending account coupled with catastrophic benefits for very large expenses. 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. White paper, Emergency department overcrowding: an action plan, Improving chronic illness care: translating evidence into action, Health care utilization among Hispanics: findings from the 1994 Minority Health Survey, Recent care of common mental disorders in the United States, Geographic variation in expenditures for physician' services in the United States, Stage at diagnosis in breast cancer: race and socioeconomic factors, Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial, Free care: a quantitative analysis of health and cost effects of a national health program for the United States, Routine outcome monitoring in a public mental health system: the impact of patients who leave care, The quality of care for depressive and anxiety disorders in the United States, Use of cancer screening practices by Hispanic women: analyses by subgroup. Welch WP, Miller ME, Welch HG, Fisher ES, Wennberg JE. Examples of such networks are the National Nosocomial Infections Surveillance system and the National Molecular Subtyping Network for Foodborne Disease Surveillance (PulseNet). Young AS, Klap R, Sherbourne CD, Wells KB. Like mental illness and addiction disorders, oral health has been neglected in the health care delivery system. Solanki G, Schauffler HH, Miller LS. Burn care beds and other special care beds intended for care that is less intensive than that provided in an ICU and more intensive than that provided in an acute care area. Key Indicators for Policy, Early and periodic screening, diagnosis and treatment and managed care, Prescribing potassium despite hyperkalemia: medication errors uncovered by linking laboratory and pharmacy information systems, Uninsured and unstably insured: the importance of continuous insurance coverage, Cost-effectiveness of practice-initiated quality improvement for depression, Best clinical practice: guidelines for managing major depression in primary care, Case studies: Montefiore Medical Center Loan, Income inequality, primary care, and health indicators, Medicaid spending growth: results from a 2002 Survey, The direct and indirect effects of cost-sharing on the use of preventive services, Acculturation, access to care, and use of preventive services by Hispanics: findings from NHANES, 19821984, The Registered Nurse Population. 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. (Additional discussion of these and other neglected forms of care appears later in this chapter.). NCVHS (National Committee on Vital and Health Statistics). Draper DA, Hurley RE, Lesser CC, Strunk BC. Aiken L, Clarke S, Sloane D, Sochalski J, Busse R, Clarke H, Giovannetti P, Hunt J, Rafferty A, Shamian J. 2002. (IOM, 2000a: 206). The shortage of RNs poses a serious threat to the health care delivery system, and to hospitals in particular. 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. 2001. 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. The move from traditional fee-for-service care models to new payment and delivery models dictates that physicians reevaluate how quality measures and payments are linked to outcomes. It includes pharmaceuticals, biotechnology and diagnostic laboratories. 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. 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). 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. Also, poor oral health can lead to poor general health. 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.

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