Health policy and management

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Health policy and management is the field relating to leadership, management, and administration of public health systems, health care systems, hospitals, and hospital networks. Health care administrators are considered health care professionals.

Contents

Terminology

Health policy and management or health systems management or health care systems management describes the leadership and general management of hospitals, hospital networks, and/or health care systems. In international use, the term refers to management at all levels. In the United States, management of a single institution (e.g. a hospital) is also referred to as "medical and health services management", "healthcare management" or "health administration".

Health systems management ensures that specific outcomes are attained, that departments within a health facility are running smoothly, that the right people are in the right jobs, that people know what is expected of them, that resources are used efficiently and that all departments are working towards a common goal.

Applying social determinants of health in health policy and management

Social determinants (i.e. location, housing, education, employment, income, crime, social cohesion) have been shown to significantly influence health. However, at present, population health receives only five percent of national health budgets. [1] By comparison, 95 percent is spent on direct medical care services, yet medical care only accounts for only 10-15 percent of preventable mortality in the United States. [1] Genetics, social circumstances, environmental exposures, and behavioral patterns comprise the bulk of health determinants of health outcomes, which is increasingly considered when creating health policy.

At the federal level, policymakers are addressing social determinants through provisions in the Affordable Care Act, in which non-profit hospitals must conduct community health needs assessments and participate in community improvement projects. [2] The creation of public-private partnerships by hospitals has occurred in many states, and has specifically addressed social determinants of health like education and housing. [3]

Federal, state, and local governments can improve population health by evaluating all proposed social and economic policies for potential health impacts. [4] Future efforts within health policy can incorporate appropriate incentives and tactical funding for community-based initiatives that target known gaps in social determinants. Needs assessments may be conducted in order to identify the most potentially effective mechanisms for each given community. Such assessments may identify a demand for increased and reliable forms of transportation, which would allow individuals to have continuous resources to preventative and acute care. As well, funding for job training initiatives within communities with low employment would allow individuals to build their capacity to not only earn income, but also engage in health-seeking behaviors which typically are at an elevated cost.

Variations in medical practice and quality of care

Unwarranted variations in medical practice refer to the differences in care that cannot be explained by the illness/medical need or by patient preferences. The term “unwarranted variations” was first coined by Dr. John Wennberg when he observed small area (geographic) and practice style variations, which were not based on clinical rationale. [5] The existence of unwarranted variations suggests that some individuals do not receive adequate care or that health resources are not being used appropriately.

The main factors driving these variations are not limited to; increasingly complex healthcare technology, exponentially increasing medical knowledge and over reliance on subjective judgement. [6] Unwarranted variations have measurable consequences in terms of over/under utilization, increased mortality, and increased costs. [7] For example, a 2013 study found that in terms of Medicare costs, higher expenditures were not associated with better outcomes or higher quality of care. [8]

Medical practice variations are an important dimension of health policy and management - understanding the causes and effects of variations will guide policymakers to develop and improve upon existing policies. In managing practice variations, it is important to perform assessments of the diseases/procedures with high levels of unwarranted variations; a comparison between the care delivered and the standard care guidelines will highlight discrepancies and provide insight into improvement areas.

Policymakers should take a comprehensive approach to align policies, leadership, and technology in order to effectively reduce unwarranted variations in care. Effective reduction requires active patient involvement and physician engagement though standardization of clinical care with a focus on adherence to care guidelines and an emphasis on quality based outcomes.

Medical industrial complex

The medical–industrial complex is the network of corporations which supply health care services and products for a profit. The term was derived from the language that President Eisenhower had used ("military-industrial complex") when warning the nation, as he was retiring, about the growing influence of arms manufacturers over American political and economic policies. [9] Then the term "medical industrial complex" started to spread from 1980 through the New England Journal of Medicine (Nov. 4, 1971, 285:1095) by Arnold S. Relman who served as an editor of the journal from 1977 to 1991. According to Dr. Relman, American health care system is a profit-driven industry and it has become a widely accepted theory these days. [10] Since the term was introduced 40 years ago, health care industry has developed into even a larger, greater and flourishing industry. Medical industrial complex includes proprietary hospitals and nursing homes, diagnostic laboratories, home care and emergency room services, renal hemodialysis units, and a wide variety of other medical services that had formerly been provided largely by public or private not-for-profit community-based institutions or by private physicians in their offices. [11]

In countries where the medical industrial complex is too influential, there are legal limitations to consumer options for accessing diverse healthcare services due to regulations in international markets such as the General Agreement on Trade in Services. [12] In the U.S, there are loose regulations on healthcare industries, often driving companies to charge high prices and fragment standards of care. For instance, pharmaceutical companies can charge high prices for drugs, as we have recently seen with EpiPen. [13] Furthermore, since manufacturers of medical devices fund medical education programs such as continuing medical education and physicians and hospitals directly to adopt the use of their devices, there is a controversy that such education has a bias to promote the interests of its funders. [14] The recent development of the telehealth industry could be a possible solution to the fragmentation of care, however, there are currently no government regulations for telehealth companies. [15] Clearly, the government must impose stronger regulations that focus on patient well-being.

Rationing and access to care

Access to care and Rationing are important dimensions of Health Policy and Management (HPAM) because they address the market force that impacts how and when people get health care services. Rationing in health care occurs due to scarcity; everyone cannot have access to every service and treatment because it would not be an efficient use of resources. Some argue that price should not be the biggest factor in determining who has access to which services and treatments, but rather that healthcare is a right that we should all have access to. [16] [17]

Preventative care is an important component of HPAM because the levels of preventative care measures taken by individuals can help to determine the health of the population. The ACA opened the door for increased access to preventative care by mandating insurers to offer these services at no additional cost. If all Americans practice the appropriate level of preventative care, “100,000 lives would be saved each year.” Even with the expanded access to preventative care services and other healthcare related services, the insured still experience rationing due to increasing premiums and rising healthcare costs.

From 2005 to 2015, the average annual employer-sponsored health insurance premiums for family coverage increased 61%. During this time, worker contribution increased even higher by 83%. The growth in employer-sponsored premiums as well as deductibles has led individuals and families to ration health care. High premiums and deductibles encourage individuals and families to think twice before they use health services and lessens the ability for individuals to consume other goods and services. [18] [ failed verification ]

In Canada citizens have a universal healthcare system which grants them access to healthcare but requires them to deal with rationing issues. The system works through level of importance, with urgent care having priority as well as certain disease/disorder treatment as some are life and death situations. Although Great Britain was the first to boast a universal healthcare system it also suffers from rationing issues. Although the no cost sharing system seems generous on the surface, the overall lack of access or options creates serious issues for patients. [19]

Imagine a world without health care rationing is impractical due to a finite amount of resources. Prior to contrary belief, universal healthcare isn’t the answer to solve rationing, in fact, rationing may increase if more people have access to healthcare without an equivalent increase in the number of physicians. Workspaces also contribute to fostering rationing amongst their employees due to high deductibles and premiums. They key in expanding access without having a negative effect on health care is to begin to look at rationing as a way to share these finite resources across the population, and not a way to reallocate care to certain people. When we do this, we can work to improve access to care and effectively treat as many patients as possible. [2] [20]

Mental health

As a field, health policy and management seeks to improve access, reduce costs, and improve outcomes for individuals with mental health conditions.

History

The history of mental health care services in the U.S. can best be understood as a gradual shift from institutionalized provision of care to interventions focused in a community setting. World War II resulted in heightened awareness of mental illness as thousands of soldiers returned home traumatized from the war. During that time, development of psychotropic medications also offered new treatment options. In 1963, John F. Kennedy implemented the Community Health Act, ending 109 years of federal non-involvement in mental health services, spurring the deinstitutionalization of individuals with mental illness. The effects of deinstitutionalization were mixed; individuals with mental illness were no longer subject to poor conditions in asylums, however, community support was inadequate to provide treatment and services for the severe and chronically ill. [21]

Delivery of services and current policy

Mental health is treated by an array of providers representing multiple disciplines working in both public and private settings. The psychiatric and behavioral health sector consist of behavioral health professionals, such as psychiatrists. The primary care sector consists of health care professionals such as internists and family practitioners. This sector is often the initial point of contact for patients. The human services sector consists of social service agencies and criminal justice/prison-based services, among others. The final sector is the volunteer support network sector, consisting of services like self-help groups. [22]

Recent legislation continues to improve access to care by requiring cost parity. The 2008 Health Parity and Addiction Equity Act required certain plans to provide mental illness coverage on par with general health coverage, requiring providers to provide care at similar out-of-pocket costs and with similar benefits for both types of care. The Affordable Care Act of 2010 (ACA) expanded this development by requiring parity for additional plans, expanding parity protections to an additional 62 million people. [23] Both acts significantly reduced cost as a barrier to care, but there are still areas for progress.

This legislation has been successful in improving mental health treatment rates across the entire population. However, there are still large disparities in these rates amongst whites and non-whites. This may be because states that opted out of Medicaid expansion under the ACA had much larger populations of adult people of color. [24]

Opportunities for improvement

An ongoing and future trend in mental health care is care integration. Recently, care integration has been a key policy priority, and numerous federal agencies have adopted initiatives to promote the integration of primary care and mental health services. [25]

Related Research Articles

A health system, health care system or healthcare system is an organization of people, institutions, and resources that delivers health care services to meet the health needs of target populations.

In common usage and medicine, health, according to the World Health Organization, is "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity". A variety of definitions have been used for different purposes over time. Health can be promoted by encouraging healthful activities, such as regular physical exercise and adequate sleep, and by reducing or avoiding unhealthful activities or situations, such as smoking or excessive stress. Some factors affecting health are due to individual choices, such as whether to engage in a high-risk behavior, while others are due to structural causes, such as whether the society is arranged in a way that makes it easier or harder for people to get necessary healthcare services. Still, other factors are beyond both individual and group choices, such as genetic disorders.

Community health refers to simple health services that are delivered by laymen outside hospitals and clinics. Community health is also the subset of public health that is taught to and practiced by clinicians as part of their normal duties. Community health volunteers and community health workers work with primary care providers to facilitate entry into, exit from and utilization of the formal health system by community members.

Health equity arises from access to the social determinants of health, specifically from wealth, power and prestige. Individuals who have consistently been deprived of these three determinants are significantly disadvantaged from health inequities, and face worse health outcomes than those who are able to access certain resources. It is not equity to simply provide every individual with the same resources; that would be equality. In order to achieve health equity, resources must be allocated based on an individual need-based principle.

<span class="mw-page-title-main">Population health</span> Health outcomes of a group of individuals

Population health has been defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group". It is an approach to health that aims to improve the health of an entire human population. It has been described as consisting of three components. These are "health outcomes, patterns of health determinants, and policies and interventions".

The social determinants of health (SDOH) are the economic and social conditions that influence individual and group differences in health status. They are the health promoting factors found in one's living and working conditions, rather than individual risk factors that influence the risk for a disease, or vulnerability to disease or injury. The distributions of social determinants are often shaped by public policies that reflect prevailing political ideologies of the area.

Patient advocacy is a process in health care concerned with advocacy for patients, survivors, and caregivers. The patient advocate may be an individual or an organization, concerned with healthcare standards or with one specific group of disorders. The terms patient advocate and patient advocacy can refer both to individual advocates providing services that organizations also provide, and to organizations whose functions extend to individual patients. Some patient advocates are independent and some work for the organizations that are directly responsible for the patient's care.

<span class="mw-page-title-main">Social medicine</span> Understanding how culture and larger groups of people shape health procedures

Social medicine is an interdisciplinary field that focuses on the profound interplay between socio-economic factors and individual health outcomes. Rooted in the challenges of the Industrial Revolution, it seeks to:

  1. Understand how specific social, economic, and environmental conditions directly impact health, disease, and the delivery of medical care.
  2. Promote conditions and interventions that address these determinants, aiming for a healthier and more equitable society.
<span class="mw-page-title-main">Rural health</span> Interdisciplinary study of health and health care delivery in rural environments

In medicine, rural health or rural medicine is the interdisciplinary study of health and health care delivery in rural environments. The concept of rural health incorporates many fields, including Wilderness medicine, geography, midwifery, nursing, sociology, economics, and telehealth or telemedicine.

<span class="mw-page-title-main">Patient dumping</span> Inappropriately releasing homeless or indigent patients

Patient dumping or homeless dumping is the practice of hospitals and emergency services inappropriately releasing homeless or indigent patients to public hospitals or on the streets instead of placing them with a homeless shelter or retaining them, especially when they may require expensive medical care with minimal government reimbursement from Medicaid or Medicare. The term homeless dumping has been used since the late 19th century and resurfaced throughout the 20th century alongside legislation and policy changes aimed at addressing the issue. Studies of the issue have indicated mixed results from the United States' policy interventions and have proposed varying ideas to remedy the problem.

John E. "Jack" Wennberg is the pioneer and leading researcher of unwarranted variation in the healthcare industry. In four decades of work, Wennberg has documented the geographic variation in the healthcare that patients receive in the United States. In 1988, he founded the Center for the Evaluative Clinical Sciences at Dartmouth Medical School to address that unwarranted variation in healthcare.

Unwarranted variation in health care service delivery refers to medical practice pattern variation that cannot be explained by illness, medical need, or the dictates of evidence-based medicine. It is one of the causes of low value care often ignored by health systems.

<span class="mw-page-title-main">Healthcare in Senegal</span>

Healthcare in Senegal is a center topic of discourse in understanding the well-being and vitality of the Senegalese people. As of 2008, there was a need to improve Senegal's infrastructure to promote a healthy, decent living environment for the Senegalese.

The Dartmouth Institute for Health Policy and Clinical Practice (TDI) has garnered significant accomplishments since its inception. Established in 1988 by John Wennberg as the Center for the Evaluative Clinical Sciences (CECS) and later reorganized in 2007 to its current form as TDI, the institute has made substantial strides in the realms of healthcare education, research, and policy

Healthcare in the United States is largely provided by private sector healthcare facilities, and paid for by a combination of public programs, private insurance, and out-of-pocket payments. The U.S. is the only developed country without a system of universal healthcare, and a significant proportion of its population lacks health insurance.

The public healthcare system in India evolved due to a number of influences since 1947, including British influence from the colonial period. The need for an efficient and effective public health system in India is large. Public health system across nations is a conglomeration of all organized activities that prevent disease, prolong life and promote health and efficiency of its people. Indian healthcare system has been historically dominated by provisioning of medical care and neglected public health. 11.9% of all maternal deaths and 18% of all infant mortality in the world occurs in India, ranking it the highest in the world. 36.6 out of 1000 children are dead by the time they reach the age of 5. 62% of children are immunized. Communicable disease is the cause of death for 53% of all deaths in India.

The social determinants of health in poverty describe the factors that affect impoverished populations' health and health inequality. Inequalities in health stem from the conditions of people's lives, including living conditions, work environment, age, and other social factors, and how these affect people's ability to respond to illness. These conditions are also shaped by political, social, and economic structures. The majority of people around the globe do not meet their potential best health because of a "toxic combination of bad policies, economics, and politics". Daily living conditions work together with these structural drivers to result in the social determinants of health.

<span class="mw-page-title-main">Healthcare in India</span> Overview of the health care system in India

India has a multi-payer universal health care model that is paid for by a combination of public and private health insurance funds along with the element of almost entirely tax-funded public hospitals. The public hospital system is essentially free for all Indian residents except for small, often symbolic co-payments in some services.

Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.

<span class="mw-page-title-main">Medical–industrial complex</span>

The medical–industrial complex is a network of interactions between pharmaceutical corporations, health care personnel, and medical conglomerates to supply health care-related products and services for a profit. The term is a product of the military–industrial complex and builds from the basis of that concept.

References

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  2. 1 2 Kovner, Anthony (April 8, 2015). Health care delivery in the United States (11th ed.). Springer Publishing. ISBN   9780826125279.
  3. ↑ Chen, M. "The Role of Hospitals in Improving Non-Medical Determinants of Community Population Health". NYS Health Foundation.
  4. ↑ Shroeder, S (September 20, 2007). "We can do better--improving the health of the American people". New England Journal of Medicine. 357 (12): 1221–8. doi: 10.1056/NEJMsa073350 . PMID   17881753.
  5. ↑ Mercuri, Mathew (April 19, 2011), "Medical practice variations: what the literature tells us (or does not) about what are warranted and unwarranted variations", Journal of Evaluation in Clinical Practice, 17 (4): 671–677, doi:10.1111/j.1365-2753.2011.01689.x, PMID   21501341
  6. ↑ Haughom, John (2014-06-16). "Clinical Variation in Your Medical Organization?". Health Catalyst. Retrieved 16 December 2016.
  7. ↑ Alexander, Dana; Kinhan, Peter; Savage, Brandon. "Eliminating Unwarranted Variation in Care" (PDF). GE Healthcare. Retrieved 16 December 2016.
  8. ↑ Newhouse, Joseph; Garber, Alan (September 25, 2015). "Geographic Variation in Health Care Spending in the United States Insights From an Institute of Medicine Report". JAMA. 310 (12): 1227–1228. doi:10.1001/jama.2013.278139. PMID   24008265.
  9. ↑ Relman, Arnold S (2005). "The health of nations". The New Republic. Vol. 232, no. 8. pp. 23–30.
  10. ↑ Angell, Marcia (August 14, 2014). "On Arnold Relman (1923-2014)". New York Review of Books.
  11. ↑ Relman, Arnold S (1980). "The new medical-industrial complex". New England Journal of Medicine. 303 (17): 963–970. doi: 10.1056/nejm198010233031703 . PMID   7412851.
  12. ↑ Santos, Maria Angelica Borges dos; Passos, Sonia Regina Lambert (August 2010). "International trade in health services and the medical industrial complex: implications for national health systems". Cadernos de Saude Publica. 26 (8): 1483–1493. doi: 10.1590/s0102-311x2010000800003 . ISSN   1678-4464. PMID   21229208.
  13. ↑ Koons, C.; Langreth, R. (September 23, 1025). "How Marketing Turned the EpiPen Into a Billion-Dollar Business". Bloomberg. Retrieved December 18, 2016.
  14. ↑ Schofferman, Jerome (2011). "The Medical-Industrial Complex, Professional Medical Associations, and Continuing Medical Education". Pain Medicine. 12 (12): 1713–9. doi: 10.1111/j.1526-4637.2011.01282.x . ISSN   1526-2375. PMID   22145759.
  15. ↑ Dorsey, E. Ray; Topol, Eric J. (2016). "State of Telehealth". N Engl J Med. 375 (2): 154–161. doi:10.1056/nejmra1601705. PMID   27410924.
  16. ↑ Reinhardt, Uwe E. "'Rationing' Health Care: What Does It Mean?". Economix Blog. Retrieved 2016-12-20.
  17. ↑ Bloche, M. Gregg (2012-05-24). "Beyond the "R Word"? Medicine's New Frugality". New England Journal of Medicine. 366 (21): 1951–1953. doi:10.1056/NEJMp1203521. ISSN   0028-4793. PMID   22551108.
  18. ↑ "The Kaiser Family Foundation". kff.org. Retrieved December 20, 2016.
  19. ↑ Payer, Lynn (1996). Medicine & culture : Varieties of treatment in the United States, England, West Germany, and France. New York: Henry Holt and Company. pp.  204. ISBN   9780805048032. OCLC   632376710.
  20. ↑ Reid, T. R. (2009). The Healing of America: A Global quest for better, cheaper and fairer health care. New York: Penguin Press. pp.  290. ISBN   9781594202346. OCLC   314597097.
  21. ↑ Sundaraman, Ramya (April 21, 2009). The U.S. Mental Health Delivery System Infrastructure: A Primer (PDF). Congressional Research Service (Report).
  22. ↑ Barry, Huskamp, & Goldman (2010). "A Political History of Federal Mental Health and Addiction Insurance Parity". The Milbank Quarterly. 88 (3): 404–33. doi:10.1111/j.1468-0009.2010.00605.x. PMC   2950754 . PMID   20860577.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  23. ↑ "Health Insurance and Mental Health Services". MentalHealth.gov. U.S. Department of Health & Human Services.
  24. ↑ Creedon & LeCook (2016). "Access to Mental Health Care Increased But Not For Substance Abuse, While Disparities Remain". Health Affairs. 35 (6): 1017–1021. doi: 10.1377/hlthaff.2016.0098 . PMC   7033262 . PMID   27269017.
  25. ↑ Mechanic (2012). "Seizing Opportunities Under The Affordable Care Act For Transforming The Mental And Behavioral Health System". Health Affairs. 31 (2): 376–382. doi: 10.1377/hlthaff.2011.0623 . PMID   22323168.
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