DISCUSSION U.S HEALTHCARE

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Meghan

The United States is recognized as one of the nations without a universal health system. 

Health care fragmentation greatly impacts patient care and is associated with patient’s receiving poor care, increased financial costs, lack of collaboration between care providers, and increased medical errors, to name a few. Additionally, a fragmented organizational structure leads to disrupted relationships, poor information flows, and misaligned incentives that combine to degrade the quality of health care in important ways (Cebul et al., 2008). An example of fragmented care is through a patient PCP. For patients with poor coordinated care, those patients are more likely to be diagnosed with chronic conditions such as diabetes or hypertension. Fragmented care through the PCP can also lead to increased patient visits to their PCP and specialists (high out of pocket cost to the patient). Healthcare reforms aimed at strengthening the primary care system have been implemented in a number of countries, both developed and developing, and have generally proven to improve the healthcare system as a whole (Chi, 2012). Organizations move away from paper charts and start taking a holistic quality of care approach, patients will start to receive a higher quality of individualized care.  Information sharing and care coordination across healthcare organizations is essential to decrease fragmentation and improve care coordination (Atasoy et al., 2021).

Another impact on a fragmented healthcare system is managed care and billing. Managed care and integrated systems represent a fundamental change in the financing and delivery of healthcare (Singh et al., 2015). Health care leaders continue to field patient complaints over outstanding bills that patients would like to dispute. There are many causes of the dispute. Sometimes the provider picks the wrong code, or the insurance company does not deem the service medically necessary, or the primary insurance carrier kicks it to the secondary carrier to pay in full. There are also changes from the payor end that are not always communicated to patient’s (the insured). An example would be: payors are requiring more testing and outpatient procedures be scheduled at an ASC (outpatient surgery center) or ambulatory services so they do not have to cover facility fees or overnight hospitalizations. For a 55-year-old male that is in need of a shoulder replacement, the payor will be more likely to approve an outpatient procedure and home therapy rather than approving the surgery at a hospital. What if the patient does not have any friends or family that he can rely on to help drive him or care for him at home?  Lastly, Patients continue to avoid healthcare appointments, routine screenings, and lab work because of the large sum of bills that will be incurred. Patients are also quite embarrassed when they present to check-in for an appointment and they are reminded that they have an outstanding balance on their account. 

Healthcare is complex and in desperate need of innovation and transformation. 

References:

Atasoy, H., Demirezen, E. M., & Chen, P. (2021). Impacts of Patient Characteristics and Care Fragmentation on the Value of HIEs. Production & Operations Management, 30(2), 563–583. https://doi-org.ezproxy.umgc.edu/10.1111/poms.13281

Cebul, R. D., Rebitzer, J. B., Taylor, L. J., & Votruba, M. E. (2008). Organizational Fragmentation and Care Quality in the U.S. Healthcare System. Journal of Economic Perspectives, 22(4), 93–113.  https://doi-org.ezproxy.umgc.edu/10.1257/jep.22.4.9

Shi. L. (2012). The Impact of Primary Care:  A Focused Review.   Scientifica . Volume 2012, Article ID 432892. Retrieved from  http://dx.doi.org/10.6064/2012/432892 /

Shi, L., & Singh, D. A. (2015). Delivering health care in America: A systems approach (Sixth edition.). Jones & Bartlett Learning.

Jasmin

The World Health Organization defines a health system as “all organizations, people and actions whose primary intent is to promote, restore, or maintain health” (WHO, 2000). Most developed countries operate following this definition through cohesive and coordinated care delivery throughout different health sectors. The same can not be said about the U.S. healthcare system. In the U.S., the term ‘system’ is used quite loosely compared to how healthcare is delivered in other countries. Here, the healthcare system comprises so many interrelated and interdependent health institutions that operate differently on the federal, state, and local levels (Piña et al, 2015). Factors such as specialized fields and innovation have created more separation and fragmentation in the delivery of care. This structure is a major contributor to higher health costs and lower patient care quality which can result in serious health risks for patients. A study in the American Journal of Managed Care researched the effects of fragmented health care on chronically ill patients. It reported that patients of primary care physicians with high fragmentation had higher rates of preventable hospitalizations. It also reported that high fragmentation was associated with higher healthcare spending, costing approximately twice as much as integrated care. This significant cost gap is mainly due to unnecessary and excessive testing and use of medication (Frandsen et al., 2015). When providers lack coordinated patient care, it can lead to conflicting treatment recommendations and prescribed medication which can potentially cause adverse effects. Although significant changes have been made to reform health care delivery, such as the Affordable Care Act (CMS 2013), considering the potential risks caused by fragmented health care, it is evident that this system should be reevaluated to serve consumers better.

References:

CMS (2013). Lower Costs, Better Care: Reforming Our Health Care Delivery System. Retrieved from  https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2013-Fact-sheets-items/2013-02-28.html

Frandsen, B. R., Joynt, K. E., Rebitzer, J. B., & Jha, A. K. (n.d.). Care fragmentation, quality, and costs among chronically ill patients. AJMC. Retrieved May 19, 2022, from  https://www.ajmc.com/view/care-fragmentation-quality-costs-among-chronically-ill-patients  

Piña, lleana L., Cohen, P. D., Larson, D. B., Marion, L. N., Sills, M. R., Solberg, L. I., & Zerzan, J. (2015). A Framework for Describing Health Care Delivery Organizations and Systems. American Journal of Public Health, 105(4), 670–679.  https://doi-org.ezproxy.umgc.edu/10.2105/AJPH.2014.301926

World Health Organization. The World Health Report 2 0 0 0 —Health Systems: Improving Performance Geneva, Switzerland: World Health Organization; 2000.