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Health Care Issues
Legislation, Trends, Challenges for Respiratory Therapy Students
Coin of the Realm
• Life--is made up of Words• Federal Register (20,689 pp as of 4/20/06)• Congressional Record• Presidential Proclamations• Newsletters• Radio & TV Talk Shows• Internet, Blogs• Congressional Hearings• Laws & Regulations
Words Have Power
• Words affect all of us:– Big Government– Health Reform– Patients’ Bill of Rights– Market Forces– Ownership Society– WMD
Law Making In Theory
• Words as Law affect us• In theory it is a simple process:
– Bill Dropped in Hopper– Referred to Subcommittee/Committee– Hearings– Rules Committee Determinations– Floor– Conference– Floor
Allied Health and Nursing
• Allied Health Funding is through Title VII, a health improvement act, but limited to section 755
• Nursing has an entire act unto itself, Title VIII
Allied Health Funding
• From these major legislative grants (Laws), Allied Health professions receive:– Scholarships– Traineeships– Student Loans– Special Project Grants– Formula Grants– Construction Grants– Training Institute Grants
THEN AND NOW
1966 200662 Senate Democrats 44 Senate Democrats 38 Senate Republicans 55 Senate Republicans295 House Democrats 202 House Democrats140 House Republicans 232 House Republicans
Lyndon B. Johnson George W. BushCongressional Seniority No SeniorityMore Receptive Climate Less ReceptiveBudget Surplus Budget Deficit
How Do You Get What You Want?
• Persuasion?
• Influence?
• Power?
ALLIED HEALTH LEGISLATION IMPERATIVES
• Workforce– Current Personnel Shortages– Student Enrollment Declines– Faculty Shortages
• Demography– Aging of Population– Fastest Growth in Oldest Cohorts
• Epidemiology– Chronic Conditions/Disability
What Is Allied Health?
• It’s NOT:
Nursing, Physician Assistants, Public Health, Chiropractic, Health Administration, Clinical Psychology, Social Work, or Counseling
Why Workforce Reform is Critical
• 60-70% of health care is labor costs
• Big part of any employment sector
• It Limits access, spurs cost increases, and directly affects quality
Broad Trends Affecting the Health Care Workforce:
• Changing Demographics
• Shifting Epidemiology
• Economic Disparity and Cost
• Technological Innovations
• Change from supply to market driven health system
Demography - Aging
Issues
• Impact on demand for health care
• Rising cost of care
• Adequate workforce
• Intergenerational equity
• Uneven across the nation
Demography - Aging
• Triple witching• Aging workforce• Fewer new workers• Care demands and
needs of an aging population
• …but, the devil in the details
Size US population by age groups
25.4 23.9 23.8
39.2 36 34.8
22.7 26.7 24.5
12.6 13.4 16.9
0102030405060708090
100
2001 2011 2021
Demography - Aging
Percentage of Population 65-84 years of age
45
79 10
11
14
17
0
5
10
15
20
1900 1920 1940 1960 1980 2000 2020 2040
Per
cen
tag
e
Epidemiology
US Life Expectancy at Birth by Gender, 1900-90
4852 55
62 6571 73 75 77 79 80
46 4854
58 6166 67 67 70 72 74
30
50
70
90
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
Yea
rs
WomenMen
Changes in Cause of Death, 1900–1999
Trend: Epidemiology
Issues• Dominantly chronic• Expensively acute• Bipolar patterns of disease and health• Less and less to do with health care--more with
lifestyle changes
Trend Three:Economic Disparity
&Cost
0
20000
40000
60000
80000
100000
120000
140000
160000
Ave
rage
Dol
lars
Lowest Second Middle Fourth Highest
Average After Tax Income by income Group(in 2000 dollars
1979
2000
Economic DisparityPercent of Population at or Below Poverty Rate
11.113
14 13.5 13.811.3 11.7 12.1
0
4
8
12
16
20
1973 1980 1985 1990 1995 2000 2001 2002
Per
cent
Economic DisparityIssues• Larger and larger number cannot afford
health care• Incumbents in health care become
wealthier• Health policy and markets driven to serve
those that have rather than need• Impact back on patterns of health and
outcomes
Technology
Next generation of technology promises to reduce cost, move care to ambulatory settings and improve outcomes.– Biomedical– Information Technology
Technology - IT
The Most Important Step is to Recognize that Health Care is a Knowledge Based Service Enterprise
• 33 Million admissions
• 4.8 Billion claims
• 505 Million outpatient visits
• 1.7 Billion prescriptions filled
Knowledge BusinessKnowledge Business
Biomedical
US investment in basic and applied biomedical leads the world
Commercial investment now surpasses public investment marking transition to application
30
40
50
60
1985 1990 1999
Percentage of Total Health R&D
Gov't Private
Growing Private Research Base
Industry spending R&D to Total NIH budget, 1992-2002
32
26
21.1
17
13.412
24
18
1412
119
0
5
10
15
20
25
30
35
1992 1994 1996 1998 2000 2002
$ B
illi
on
Market Driven HealthFrom Supply Based to Demand
Driven
Cost
DEMAND
ConsumerSatisfaction
Quality
Market PressuresHealth care has been based on the
individual:EncountersFinancingEthicsRelationshipsOutcomes
New challenge:
How to balance the tradition of individualism with the needs of:Population healthSystem outcomesBroader social needsDesire to balance equity and choice
Consumer
Issues• Wants choice ….but at what price?• Increasingly willing to buy value… quality,
access and cost• Needs are more segmented then care
systems acknowledge…build it and they will come
• Inevitable exposure to more costs … will look for help to address
Demography - Diversity
From a majority culture...
0
10
20
30
40
50
60
70
80
Perc
enta
ge
White Black Hispanic Asian/PI Am Indian
Percentage Ethnicity of US Population, 95, 05, 25
199520052025
To diversity...
To multicultural.
Diverse to Multicultural
0
10
20
30
40
50
60
Per
cent
age
White Black Hispanic Asian/PI Am Indian
Ethnicity of CA Population, 95,05,25
199520052025
Continued Disequilibrium in Health Care
• Costs--Total system costs are a huge burden
• Variation--Enormous range in definition of quality
• Over/under supply of care providers, hospitals, insurers.
• Duplication--Substitutable inputs• Access--+15% uninsured
How Did This Emerge?
Past• Constantly expanding health system
• Little accountability - cost or quality
Transition from simple and independent to complex and highly interdependent
What is driving the issue?
Stressed care delivery system and institutions– Tighter resources– Lack of direction– Greater demands
• Technology
• Quality – Job cuts – Uncertainty– Inability to adapt and change rapidly
• Changing nature of work– Faster– Flatter– Flexible
• Changing demographics– Race/Ethnicity– Aging Population
• New values– Women in labor market– Gen X workers
New Values
• Next Generation Worker Want:
• Service oriented• Anti-institutional• Not hierarchical• Flexible, change
welcoming • Diversity• Technology• New skills• Community of work
Hospital Image• Staff is on strike, laid-off,
or Angels of Mercy• Large, cold, unresponsive
institutions• Work is stressful, highly
structured, and un-fun• Tied to a professional
career, not open to change
Problems
• Scope(s) of practice
• Professional Models
– Both unimaginative, traditional, turf building or turf keeping
Angels of Mercy?
• The historical success of a profession rests fundamentally on the growth of its particular source of wealth and status—its authority. Acknowledged skills and cultural authority are to the professional classes what land and capital are to the propertied. They are the means of securing income and power.
Paul Starr--The Social Transformation of American Medicine
Hippocratic Oath
• What is the first statement in this oath?
• We think it is, “above all (or first), do no harm”
• But. . .
I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others.
Modern Version of the Oath
• I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
Beware Professional Interests:
• Policy history is guided by the interests of individual professions
• Population health concerns are secondary• Partnerships are accepted reluctantly• Guild mentality pervades everything• The future of health care should NOT be
determined by internecine struggles• Most are subject to the same demographic,
social, and economic pressures
Transition Dynamics in Health Care
Can our professional models survive?
• COST UNAWARE ------------------------- COST ACCOUNTABLE
• TECHNOLOGICALLY DRIVEN ---HUMANELY BALANCED
• INSTITUTION BASED --------------- COMMUNITY FOCUSED• PROFESSIONAL------------------------------------- MANAGERIAL
• INDIVIDUAL ------------------------------------------- POPULATION
• ACUTE --------------------------------------------------------- CHRONIC• TREATMENT ------------------- MANAGEMENT/PREVENTION
• INDIVIDUAL PROVIDER ------------------------------------- TEAM
• COMPETITION ------------------------------------ COOPERATION
• DISAGGREATED--------------------------------------INTEGRATED
We need to re-examine professional models
– Scopes of Practice– Specialist – Generalist relationship– Organization of professional governance– Financing of care services– Training and specialization– New skill acquisition– Continuing competence
Key Questions:
• What are the broad health workforce needs to be met?
• What changes must be made to meet those needs?
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