health insurance (hucj1)

HCA 3305, Health Unit Coordination 1

Course Learning Outcomes for Unit I Upon completion of this unit, students should be able to:

1. Analyze major historic trends affecting health care delivery in the United States. 1.1 Identify major U.S. historical events known to have shaped present-day health. 1.2 Compare and contrast changes to payment mechanisms and the overall cost of health care

over the last 6 decades. 1.3 Examine trends regarding care providers and prominent practice settings affecting present day

health care delivery. 1.4 Explain paradigm shifts occurring within the health care industry in recent years.

Course/Unit

Learning Outcomes Learning Activity

1.1 Unit Lesson Chapter 2 (3 sections) Unit I Assessment

1.2 Unit Lesson Chapter 2 (3 sections) Unit I Assessment

1.3 Unit Lesson Chapter 2 (3 sections) Unit I Assessment

1.4 Unit Lesson Chapter 1 Unit I Assessment

Required Unit Resources Chapter 1: The Evolving Supervisory Role Chapter 2: The Volatile Healthcare Environment—Read the following sections:

• For Consideration: Predictions Are Strange Phenomena • The Managed Care “Solution” • The Balanced Budget Act of 1997

Unit Lesson Understanding the history of health care delivery, payment mechanisms, and cost is essential to understanding the scope of the current limitations within the U.S. health care system, and more importantly, to drive forward the work necessary for improvement. The historical knowledge comes from understanding key historical events, the progression of health care funding, changes to health care costs over time for citizens, and the makeup of labor forces to provide care coupled with how care delivery settings have evolved over time.

UNIT I STUDY GUIDE U.S. Health Care Delivery Trends

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Major Events in Health Care Delivery 1796 – First attempt at vaccination: Edward Jenner used cowpox, a mild virus that affects cattle, to vaccinate a boy against smallpox. Although Jenner was unsure how the virus behaved, he hypothesized that it was related to another virus affecting farm animals known as horsepox. After the vaccination, Jenner purposely exposed the boy to smallpox and he did not contract the fatal virus (The College of Physicians of Philadelphia, n.d.). 1847 – Establishment of the American Medical Association (AMA): The AMA began as a group centered on the needs of physicians and focused on regulating medical training. Initially, medical training was loosely run by physicians. In the early stages, there were a lot of inconsistencies in medical education, and it lacked the rigor of present-day medical education. The Flexner Report of 1910, which scrutinized medical schools in the United States and Canada, was responsible for the development of standardized core curriculum and rigorous admission testing that still exists today, known as the Medical College Admission Test or MCAT (Niles, 2014). 1850s – Development of organized hospitals: Initially, hospitals as we know them today, were designed to treat the poor and attempt to stop the spread of disease. The very first hospitals were known as almshouses or poorhouses. If they were government-operated, they were referred to as pesthouses, specifically aimed at halting the spread of disease among the poor. Systems of hospitals began to be established, but they had a lot of room for improvement in the way of conditions and skilled providers. In the beginning, hospitals were primarily operated by the physicians who treated patients there (Niles, 2014). 1866 – First public health department in New York City: This came about in part because of the work of John Hoskins Griscom to shed a light on sanitation conditions in the city. Health agencies began around the same time in a handful of other places across the country. In general, public health saw its beginnings in the 19th century where an awareness of the link between grime and disease was born, and cleanliness became the new standard to promote health and wellbeing (Institute of Medicine Committee for the Study of the Future of Public Health [IOM], 1988). 1928 – Penicillin is discovered by Alexander Fleming: This accidental discovery changed the trajectory of medicine by offering treatment for infectious illnesses. Before the discovery of penicillin, many people died from simple illnesses and infections. During this discovery, Fleming specifically noted the effect of penicillin on staphylococci, a type of bacteria, in his lab. During World War II, penicillin is noted to have decreased the mortality rate of bacterial pneumonia in soldiers from 18% to almost no deaths at all. The discovery of penicillin is also known to have supported the development of countless other antibiotics needed to combat antibiotic-resistance within bacteria over the years (Rayner, 2020). 1929 – Narcotic Control Act: This was the first presidential act aimed at addressing drug dependence (Niles, 2014). Over the next 20 to 30 years, there was a clear shift toward the illegality of drugs and stiffer penalties for certain drug-related offenses (Sacco, 2014). 1935 – Social Security Act: The United States becomes one of the first countries to support its elderly. During this era, there was significant hope and work done to promote national health insurance that would cover all citizens. However, the financial crises caused by the Great Depression and later World War II kept the concept of insurance for all from ever coming into existence (Niles, 2014). 1946 – National Mental Health Act: This is the first organized attempt to fund study, deterrence, and care for mental health (Niles, 2014). At the heart of this legislation were veterans from World War II, who to date had received abysmal care for mental illness from the Veteran’s Administration. President Truman’s law is also credited with beginning the National Institute of Mental Health (NIMH). To understand the gravity of the mental health crisis during this time, the NIMH began with a budget of $8.7 million. By 1967, the budget exceeded $315 million (Herman, 1995).

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1966 – The Donabedian model: This framework for assessing quality in health care is first introduced by Dr. Avedis Donabedian. The aim of this model highlights the undeniable relationship between care structure and processes and the effect on patient outcomes (Marjoura & Bozic, 2012). 1973 – Patient Bill of Rights: This was established in 1973 and aimed at protecting the consumers of health care (Niles, 2014). Some key rights contained within include a patient’s right to respectful care, the right to make decisions about one’s own care, the right to informed of medical choices, and the right to view one’s own medical records. At the same time, patients have duties outlined in the Bill of Rights, including an obligation to be forthcoming about one’s past medical history, the duty to provide a hospital with a copy of any advanced directives, and the commitment to work with insurance companies and the hospital itself to ensure payment collections (Pecorino, 2002). 1974 – Certificate of Need (CON) law: This law required states to oversee the building of or expansion of hospitals to limit competition within the health care industry. Despite being rescinded in 1987, to date, 36 states still have some form control over hospital expansion (Niles, 2014). 1986 – The Emergency Medical Treatment and Active Labor Act (EMTALA): This is enacted by Congress, ensuring access to emergency treatment and prevent hospitals from transferring uninsured patients to the detriment of their health. The law stemmed from a concept known as patient dumping, most prominently discussed within the context of Cook County Hospital in Chicago, where other facilities would transfer uninsured and otherwise undesirable patients there for treatment. In the 1980s, 94% of patients transferred to Cook County Hospital had not provided consent to be transferred. These unethical transfer practices resulted in a mortality rate two times higher than the patients treated at other Chicago hospitals (Zibulewsky, 2001). 1996 – Advent of hospitalist and the hospital medicine specialty: This changed the way care is delivered in U.S. hospitals. A hospitalist physician forgoes an office practice and solely cares for patients admitted to the hospital. Since the inception of hospitalists, great debate exists on the exact value of the hospitalist physician. Some experts contend there is a clear reduction in costs and increased efficiency for the hospitalized patient cared for by a hospitalist. However, many experts contend that patient outcomes suffer because hospitalists lack personal knowledge about a hospitalized patient’s medical history (Palabindala & Salim, 2018). 2000 – To Err is Human is published by the Institute of Medicine: This provides groundbreaking focus on safety in health care by reporting that approximately 98,000 people die annually as a result of errors by health care providers and systems (Marjoura & Bozic, 2012). At the epicenter of this report is the concept that health care providers are not responsible for most errors in health care, but rather faulty processes and systems in which the providers practice. It is this groundbreaking concept that has changed how patient safety is viewed presently and, most importantly, highlighted how a policy report such as this can spur national attention and prioritization within the health care industry (Stelfox et al., 2006). 2002 – National Patient Safety Goals (NPSGs): The Joint Commission releases standards to inform consumers of hospital requirements for quality and safety (Niles, 2014). These standards assisted health care organizations to address key issues regarding patient safety. These standards focus on vital processes necessary to keep patients safe such as patient identification, communication among caregivers pertaining to critical results, medication safety, the prevention of health care-associated infections, reducing alarm fatigue, and the reduction of other preventable adverse conditions such as falls and pressure ulcers (The Joint Commission, 2021).

The Evolution of Payment Mechanisms and Health Care Costs in the United States 1950s – Only 57% of the U.S. population had insurance covering hospital care (Niles, 2014). 1965 – Medicare program is enacted by President Lyndon Johnson, which was a national insurance for the elderly. Initially, the plan was for the program to expand to insure children and ultimately every citizen. Medicare was expanded to include persons of any age with end-stage renal disease and certain permanent disabilities; however, Medicare continues to fall short of insuring all citizens (Oberlander, 2019).

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1973 – Health Maintenance Organizations (HMOs) emerge, which expand private health insurance coverage choices (Harrill & Melon, 2021). The HMO Act mandated any employer with greater than 25 employees is required to offer an HMO plan if it already offers health insurance to its employees (McConnell, 2019). HMOs provide rules regarding the utilization of some health care services in exchange for controlled costs. However, controlling costs often means fewer choices for consumers. 1985 – Consolidated Omnibus Reconciliation Act (COBRA) provides ongoing health coverage to terminated employees (Niles, 2014). The biggest issue with COBRA is the cost of premiums under the plan. When a worker is employed, the employer pays a large portion of the worker’s insurance premiums that become the responsibility of the worker under COBRA. COBRA traditionally has had a very low enrollment, seen as cost- prohibitive by most (Agarwal & Sommers, 2020). 1996 – Health Insurance Portability and Accountability Act (HIPAA) allows people more flexibility to change jobs without negatively impacting health insurance coverage (Niles, 2014). Additionally, this act is responsible for national guidelines that protect a consumer’s private health information. Governed under the U.S. Department of Health and Human Services (HHS), health care entities are provided strict guidelines that direct the flow of patient information to provide continuity of care while ensuring privacy through rules that govern disclosure (Centers for Disease Control and Prevention [CDC], 2018). 2007 – The term value-based care was coined as an overarching reform model based upon managing the patient experience, costs, and clinical outcomes (Harrill & Melon, 2021). Teisberg et al. (2020) describe a framework necessary to achieve value in health care that includes expanded partnerships between consumers, health plans, clinicians, and suppliers; better measurements of cost and outcomes; incorporated learning teams; complete solutions to improve health outcomes versus fragmented services; and better understanding of the needs of patients to ensure more integrated and efficient care. 2010 – The Patient Protection and Affordable Care Act (PPACA) is enacted by President Barack Obama. It is also known in part as Obamacare. Aims of the PPACA included a comprehensive requirement for health insurance and rid the industry of the right to deny insurance based upon preexisting conditions. The act was also aimed at addressing health care quality and accessibility (Rosenbaum, 2011). 2011 – Accountable Care Organizations (ACOs) emerge as part of the PPACA. The fundamental basis is shared risk and cost savings between payer and physician aimed at increasing quality and reducing costs (Harrill & Melon, 2021). ACOs were developed to lessen fragmentation of care and increase care coordination (Marjoura & Bozic, 2012). 2013 – The Center for Medicare & Medicaid Services (CMS) develops bundle care initiatives aimed at sharing payments across hospitals and post-acute care partners for episodes of care for certain patients (Niles, 2014). Essentially, bundled care forces reimbursement away from the traditional fee-for-service toward value- based care. There are various models under the bundled care initiative, and it is voluntary for health care organizations and providers to join. The model includes 48 different medical and surgical-type patients, where there is a reward (higher reimbursement) issued for cost-effective, high-quality care, or penalized if costs exceed the preset threshold (Hardin et al., 2017).

Understanding the Cost of Health Care: Then and Now From 1960 to 2019, the explosion of the cost of health care can probably best be understood in the jump in the percentage of the U.S. gross domestic product (GDP) from 5% to 17% (Harrill & Melon, 2021). Explained another way, the United States spent $74.1 billion on health care in 1970; $1.4 trillion in 2000; and by 2019, the cost of health care skyrocketed to exceed $3.8 trillion (Kurani et al., 2022).

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According to Kurani et al. (2022), in 2019, the attribution of national health care costs was:

Entity % Contribution

Hospitals 31%

Physicians and clinics 20%

Prescriptions drugs 10%

Nursing care 5%

Dental 4%

Home health care 3%

Other health (combined) 27%

Changes to Health Care Delivery: People and Settings

Prior to 1960, health care delivery was dominated by physicians. In the 1960s, the role of the nurse practitioner or advanced nurse emerged to help ease the physician burden, especially in rural areas (Pankau, 2021). In 1965, the first academic physician assistant program began at Duke University in response to the extreme lack of physicians. According to the World Health Organization (2010), presently only 9% of physicians practice in rural areas, but these areas comprise more than 20% of the population. Accordingly, the need for mid-level providers has grown dramatically. Pankau (2021) reports a forecast increase in both nurse practitioners and physician assistants to increase by 72% by the year 2025. Historically, at the epicenter of the U.S. health care system were independent physicians and self-sustained hospitals providing care to patients. Further, payers were not involved in the planning of care for patients, which was left solely to physicians. Today, there exists a clear paradigm shift toward preventative care, a focus on resource stewardship and reducing expensive treatments, and quality improvement. Often, the payer is as much at the center of care decisions as the physician (Conklin, 2002). Other changing trends are gaining momentum in United States, such as the need to ration care in some instances, large-scale mergers and acquisitions resulting in job loss and hospital closures, and the demand to lower costs while improving care, which are stark contrasts to the previously held beliefs of the system (McConnell, 2019). Traditionally, hospitals provided the largest percentage of care to the sick and injured. However, in 2009, hospital admissions have begun to slowly decline, mostly because of the outcry related to skyrocketing health care costs (Norwich University Online, 2018). Specifically, hospital admissions dropped by 2% from 2012 to 2013 with a 1.2% increase in outpatient visits during same time period. Further, there has been a steady decline in the number of available hospital beds in the United States, while the number of admissions has rapidly increased. Specifically, in 1950, there were 1.46 million available hospital beds in this country used to support 18.48 million patient admissions. In 1996, those numbers changed to 1.06 million available beds needed to support an astounding 33.31 million admissions (Conklin, 2002).

Conclusion The U.S. health care system has been wrought with changes affecting the state of health care delivery today. Prominent changes have been seen in payment mechanisms, cost, provider roles, and even the settings in which care is delivered. Understanding historical perspectives is vital to a new health care leader charged with shaping the future of care delivery in this country.

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References

Agarwal, S. D., & Sommers, B. D. (2020, October 22). Insurance coverage after job loss – The importance of the ACA during the COVID-associated recession. The New England Journal of Medicine, 383, 1603– 1606. https://www.nejm.org/doi/full/10.1056/NEJMp2023312

Centers for Disease Control and Prevention. (2018, September 14). Health Insurance Portability and

Accountability Act of 1996 (HIPAA). U.S. Department of Health & Human Services. https://www.cdc.gov/phlp/publications/topic/hipaa.html

The College of Physicians of Philadelphia. (n.d.). The history of vaccines.

https://www.historyofvaccines.org/timeline#EVT_48 Conklin, T. P. (2002, Fall). Health care in the United States: An evolving system. Michigan Family Review,

7(1), 5–17. http://dx.doi.org/10.3998/mfr.4919087.0007.102 Hardin, L., Kilian, A., & Murphy, E. (2017, June). Bundled payments for care improvement: Preparing for the

medical diagnosis-related groups. The Journal of Nursing Administration, 47(6), 313–319. http://dx.doi.org/10.1097/NNA.0000000000000492

Harrill, W. C., & Melon, D. E. (2021, June). A field guide to U.S. healthcare reform: The evolution to value-

based healthcare. Laryngoscope Investigative Otolaryngology, 6(3), 590–599. http://dx.doi.org/10.1002/lio2.575

Herman, E. (1995). The romance of American psychology: Political culture in the age of experts. University of

California Press. Institute of Medicine Committee for the Study of the Future of Public Health. (1988). The future of public

health: 3. A history of public health. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK218224/

The Joint Commission. (2021, January). National Patient Safety Goals.

https://www.jointcommission.org/standards/national-patient-safety-goals/- /media/b35ba0b4b9754c6dbafdb1f86e152e5c.ashx

Kurani, N., Ortaliza, J., Wager, E., Fox, L., & Amin, K. (2022, February 25). How has U.S. spending on

healthcare changed over time? Peterson-KFF Health System Tracker. https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed- time/#:~:text=Health%20spending%20totaled%20%2474.1%20billion%20in%201970.%20By,on%20h ealth%20more%20than%20doubled%20to%20%243.8%20trillion

Marjoura, Y., & Bozic, K. J. (2012). Brief history of quality movement in US healthcare. Current Reviews in

Musculoskeletal Medicine, 5, 265–273. http://dx.doi.org/10.1007/s12178-012-9137-8 McConnell, C. R. (2019). The effective health care supervisor (9th ed.). Jones & Bartlett Learning. Niles, N. J. (2014). Basics of the U.S. health care system (2nd ed.). Jones & Bartlett Learning. Norwich University Online. (2018, September 12). From inpatient to outpatient: The evolution of healthcare

delivery. https://online.norwich.edu/academic-programs/resources/inpatient-outpatient-evolution- healthcare-delivery

Oberlander, J. (2019, November). Lessons from the long and winding road to Medicare for all [Editorial].

American Journal of Public Health, 109(11), 1497–1500. https://libraryresources.columbiasouthern.edu/login?url=https://search.ebscohost.com/login.aspx?dire ct=true&db=asn&AN=138917841&site=ehost-live&scope=site

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Palabindala, V., & Salim, S. A. (2018). Era of hospitalists. Journal of Community Hospital Internal Medicine Perspectives, 8(1), 16–20. http://dx.doi.org/10.1080/20009666.2017.1415102

Pankau, T. (2021). The growing use of mid-level practitioners in the delivery of health care. DePaul Journal of

Health Care Law, 22(2). https://via.library.depaul.edu/jhcl/vol22/iss2/3 Pecorino, P. A. (2002). Medical ethics: An online textbook. The City University of New York.

https://www.qcc.cuny.edu/SocialSciences/ppecorino/MEDICAL_ETHICS_TEXT/Table_of_Contents.ht m

Rayner, C. (2020). How the discovery of penicillin has influenced modern medicine. The Oxford Scientist.

https://oxsci.org/how-the-discovery-of-penicillin-has-influenced-modern-medicine/ Rosenbaum, S. (2011). The Patient Protection and Affordable Care Act: Implications for public health policy

and practice. Public Health Reports, 126(1), 130–135. http://dx.doi.org/10.1177/003335491112600118

Sacco, L. N. (2014, October 2). Drug enforcement in the United States: History, policies, and trends (CRS

Report No. R43749). Congressional Research Service. https://sgp.fas.org/crs/misc/R43749.pdf Stelfox, H. T., Palmisani, S., Scurlock, C., Orav, E. J., & Bates, D. W. (2006). The “To Err is Human” report

and the patient safety literature. BMJ Quality and Safety, 15(3), 174–178. http://dx.doi.org/10.1136/qshc.2006.017947

Teisberg, E., Wallace, S., & O’Hara, S. (2020). Defining and implementing value-based health care: A

strategic framework. Academic Medicine, 95(5), 682-–685. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7185050/

World Health Organization. (2010, February). Mid-level providers: A promising resource to achieve the health

Millennium Development Goals. https://www.researchgate.net/publication/281091793_Mid- level_health_providers_- _a_promising_resource_to_achieve_the_health_Millennium_Development_Goals_Final_Report_Cont ributing_Author_WHO_GHWA_2010

Zibulewsky, J. (2001). The Emergency Medical Treatment and Active Labor Act (EMTALA): What it is and

what it means for physicians. Baylor University Medical Center Proceedings, 14(4), 339–346. http://dx.doi.org/10.1080/08998280.2001.11927785

Suggested Unit Resources In order to access the following resource, click the link below. Oberlander, J. (2019). Lessons from the long and winding road to Medicare for all [Editorial]. American

Journal of Public Health, 109(11), 1497–1500. https://libraryresources.columbiasouthern.edu/login?url=https://search.ebscohost.com/login.aspx?dire ct=true&db=asn&AN=138917841&site=ehost-live&scope=site

Learning Activities (Nongraded) Nongraded Learning Activities are provided to aid students in their course of study. You do not have to submit them. If you have questions, contact your instructor for further guidance and information. In your eTextbook, look at Review Question # 3: Reflection and Application to Your Current Role in Chapter 1. Think about what is meant by the claim that job security now resides in flexibility, adaptability, and performance.