Upload
lenard-foster
View
213
Download
0
Tags:
Embed Size (px)
Citation preview
Access to Care
M6920November 13, 2001
Columbia University School of Nursing M6920, Fall, 2001
Definition of Access
Care when YOU want it Care you can afford without
undercutting other needs Care you are comfortable with Care which adds to your health
status
Columbia University School of Nursing M6920, Fall, 2001
fieldmodelnurs10.gif
Columbia University School of Nursing M6920, Fall, 2001
0.2
< 44.1-12
0.8
2.1
14.0
3.5
2.0
1.61.7
3.70.6 0.3
0.1
0.00.3
0.1
0.2
0.0
0.10.0
0.2
0.5
0.4
0.2
0.1
R ate per 100,000population14.4
> 12
1.0
3.0
1.2 3.5
0.3
0.3
VTN HM AR IC TN JD EM D
0.00.01.30.21.91.93.0
17.6
Primary and secondary syphilis - Rates by state:United States and outlying areas, 1997
N ote: The to ta l ra te of prim ary and secondary syph ilis for the U nited S tates and outly ing areas (including G uam , Puerto R ico, and V irg in Is lands) w as 3 .3 per 100,000 popula tion.
3.5
The H ealthy People year 2000 ob jective is 4.0 per 100,000 population
3.5
1.1
(n=42)(n=7)(n=3)
2.62.1
6.7
Virg in Is.Puerto R ico 1.8
G ua m 0.0 7.0
6.9 10.2
8.4
9.6
9.8
Columbia University School of Nursing M6920, Fall, 2001
0.2
< 44.1-12
0.6
1.8
13.5
3.3
1.8
1.41.9
3.20.8 0.2
0.0
0.00.2
0.1
0.3
0.0
0.00.0
0.2
0.6
0.3
0.0
0.0
Ra te p e r 100,000p o p ula tio n
14.2
> 12
0.8
1.7
0.7 3.3
0.1
0.3
VTN HM AR IC TN JD EM D
0.00.01.00.21.51.42.7
15.4
Primary and secondary syphilis - Rates for women by state:United States and outlying areas, 1997
N ote: The to ta l ra te of prim ary and secondary syph ilis fo r w om en in the U nited S tates and outly ing areas (includ ing G uam , Puerto R ico, and Virg in Is lands) w as 2.9 per 100,000 popula tion.
3.1
The H ealthy People year 2000 objective is 4 .0 per 100,000 population.
3.3
0.8
(n=43)(n=7)(n=3)
2.72.2
6.0
Virg in Is.Puerto R ico 0.0
G uam 0.0 5.1
7.9 9.0
8.3
8.2
9.4
Columbia University School of Nursing M6920, Fall, 2001
Primary and secondary syphilis - Counties with rates above and counties withrates below the Healthy People year 2000 objective: United States, 1997
R ate per 100,000population
<4
>4
(n=2,702)
(n=413)
Columbia University School of Nursing M6920, Fall, 2001
Barriers for Vulnerable Populations
Population Organizational Bars Financial Bars
Chronically ill Array of servicesincomplete
Restrictive eligibility
Persons with AIDS Service gaps, providerfears
Exclusion fromcoverage
Substance abusers Fragmented service,cultural insensitivity
Imbalance in financingbetween public/private
Columbia University School of Nursing M6920, Fall, 2001
Timing of care
symptoms occur you can get to it
• missing work• transportation
an authority figure says so• parent• employer • practitioner
Columbia University School of Nursing M6920, Fall, 2001
Affordability of care
insurance coverage out of pocket expenses for the care collateral expenses
• prescriptions• supportive aids• assistance
lost opportunity costs
Columbia University School of Nursing M6920, Fall, 2001
Uninsured midlife adults
0%
10%
20%
30%
40%
50%
60%
70%
80%
Went withoutcare
Had billproblems
Had accessor bill
problems
Insured
Uninsured
Commonwealth Fund 1999 National Survey of Workers’ Health Insurance
Columbia University School of Nursing M6920, Fall, 2001
Medicare Recipients with Income $10,000/yr.
0%
10%
20%
30%
40%
50%
60%
65-84 85 and up
MenWomen
Columbia University School of Nursing M6920, Fall, 2001
Insured, but how?
Perceived typeof plan
Actual plan isHMO
Actual plan isNon-HMO
HMO 35% 13%Non-HMO 11% 41%
0
2
4
6
8
10
12
% Dissatisfied
In HMO/ReportHMO
Non-HMO/ReportHMO
In HMO/Reportnot
Non-HOM/Report Not
Center for Studying Health System Change Issue Brief #30
Columbia University School of Nursing M6920, Fall, 2001
Who are the uninsured?
Contingent workers Part-time workers Small/individual businesses Early retirees High-cost individual insurees Un-enrolled Medicare/Medicaid
eligibles
Columbia University School of Nursing M6920, Fall, 2001
Individual insurance costs
Hypothetical individuals submitted to 19 companies in 8 markets (60 per person)
Asked to underwrite a policy with $500 deductible and $20 co-pay per office visit
response might be• “clean offer” = standard coverage and rate• coverage with restrictions in a rider• coverage at a higher rate• refused coverage
Kaiser Family Foundation #3133
Columbia University School of Nursing M6920, Fall, 2001
Case 1
24 yo with hay fever• rejected 5 times• 46 of 55 limitation• range $408-$4,596/ year
Columbia University School of Nursing M6920, Fall, 2001
Case 2
36yo 10yr post knee repair• rejected 7 times• 15 clean offers• range $588 -$5,112/ year
Columbia University School of Nursing M6920, Fall, 2001
Case 3
48yo 7yr breast CA survivor• 26 rejections• 11 clean offers• range $1,464-/416,344/year
Columbia University School of Nursing M6920, Fall, 2001
Case 4
Family (36 yo parents, 10 yo, 12 yo with asthma and Otitis Media)• 9 offers excluded 12 yo• many riders/increases• range $1,692-$15,444/year
Columbia University School of Nursing M6920, Fall, 2001
Case 5
62 yo overweight smoker• rejected 33 times• 2 clean offers• range $9,936-$20,048/year
Columbia University School of Nursing M6920, Fall, 2001
Kaiser Family Foundation #3133
Case 6
36yo HIV positive• rejected 60 times
Columbia University School of Nursing M6920, Fall, 2001
%Uninsured by race, ethnicity
0
5
10
15
20
25
30
35
1990 1998
White
African-American
Hispanic
United Hospital Fund, March, 2000
Columbia University School of Nursing M6920, Fall, 2001
Comfort with care
language• care through trained translators• family translators
culture style
• formality/informality• "charity" attitude
Columbia University School of Nursing M6920, Fall, 2001
Language barriers
0102030405060708090
100
Selfreport
DX good
Selfreport Dx
poor
Selfreport Tx
good
Selfreport Tx
poor
Wishbetterexplan
No wishfor more
No needinterpreter N240
interpreter used(n121)
no interpreter(N102
Baker et al, JAMA 275:10, Pg. 783-88
Columbia University School of Nursing M6920, Fall, 2001
Care which adds to health
minimize excess access increase access to
prevention/screening fill particular gaps, such as mental
health services
++++++
Columbia University School of Nursing M6920, Fall, 2001
Hepatitis B and Hepatoma
“Attention must be paid. Life must be prolonged”
All the support and encouragement you can muster:• CDC web site: www.cdc.gov• WHO web sit: www.who.int• Hepatitis Central web site: www.hepatitis-
central.com• American Liver Foundation web site:
gi.uscf.edu/alf.html
Columbia University School of Nursing M6920, Fall, 2001
Infergen®-ConsensusInterferon
Infergen®: has Triple the success rate of Combination therapies in Consensus Interferon Trials Infergen®
Testing of Maxamine™ and Infergen® Infergen® Package Insert for Patients
Columbia University School of Nursing M6920, Fall, 2001
Liversupport.com
You are here because you or someone you care about has a liver disease or concern and you want to learn what you can do about it.
• What you discover on this site will definitely help you.
• To begin with, a scientifically-proven nutritional supplement you will read about here is actually prescribed by doctors in Europe.
Columbia University School of Nursing M6920, Fall, 2001
Liversupport.com
European physicians routinely prescribe this substance specifically to help protect and support liver function in patients with serious liver concerns (including chronic hepatitis and cirrhosis).
Columbia University School of Nursing M6920, Fall, 2001
Liversupport.com
Now, in the USA, you can get the most powerful form of this valuable substance without a doctor's prescription, and we will tell you how. • Click here to learn more about this safe
and powerful liver protector along with other helpful information for liver patients
www.LiverSupport.com ©
Columbia University School of Nursing M6920, Fall, 2001
The preceding brought to you by
Olympus microscopes SmithKline Beecham
pharmaceuticals
Columbia University School of Nursing M6920, Fall, 2001
According to CDC analysis
For treatment of hepatitis C, interferon alone is 7-10% effective
In combination treatment, persistent effectiveness is at the 15% level.
Columbia University School of Nursing M6920, Fall, 2001
United States Canada Germany
Access: unable to see specialist 23% 18% 10%
Unable to get dx. tests 22 22 13
Unable to get care 23 13 9
Postponed care 34 20 14
Specialists: Choice not adequate 16% 27% 10%
Long wait 20 34 30
Average wait for appointment 5 days 14 days 4 days
Time Dr or Nurse spent 25 min. 19 min. 19 min.
Did not have blood pressure check last year
11% 17% 21%
*ADAPTED FROM HEALTH AFFAIRS, Summer, 1996 Datawatch
Health Affairs Summer, 1996 Datawatch
Access to care by those with significant problems
Columbia University School of Nursing M6920, Fall, 2001
Ways to achieve a policy outcome
State preference and hope? Legal requirements/sanctions
• Economic sanctions • Business sanctions Contractual incentives
Contractual commitments• Pay if you do• Withhold pay if you don’t
Columbia University School of Nursing M6920, Fall, 2001
Potential actions
Provider Standards Fee for service License
requirements Capitation contracts Penalty for failure to
meet goals
Patient education Reduced rates for
response Reduced co-pays or
deductible Material rewards for
participation
Columbia University School of Nursing M6920, Fall, 2001
Actions to increase access
Financial access• expansion of Medicaid
• Oregon Plan• Raising limits for prenatal to 300% (1990)
• COBRA (1987)• Medical Savings Accounts (1996)• CHIP (1997)
Columbia University School of Nursing M6920, Fall, 2001
Red: separate planYellow: MedicaidTurquoise: Combined
CHIP plans by state
Columbia University School of Nursing M6920, Fall, 2001
Negative impact of welfare reform
In 1995, 88% of poor children received food stamps
Medicaid and food stamp eligibility have not changed with welfare reform
In 1998, 70% of poor children received food stamps
Columbia University School of Nursing M6920, Fall, 2001
Increasing access, cont.
geography• Hill Burton Hospitals
geography/finances• OEO Neighborhood health centers• 330 Migrant Community Health
Centers• Community mental health centers
Columbia University School of Nursing M6920, Fall, 2001
Increasing access, cont.
geography/culture• 330 neighborhood board approach• "community health workers"--IHS• requirements for translation services
disability• Handicapped access laws• Americans with Disabilities Act
Columbia University School of Nursing M6920, Fall, 2001
Average Hours in Charity Care in Previous Month
0123456789
10
% Revenue from Managed Care
0%1-20%21-40%41-60%61-84%>85%
Columbia University School of Nursing M6920, Fall, 2001
Changes in charity care
%providing
Averagehours/mo.
1996-97 76% 11.1
1998-99 72% 10.6
Change -4%** -0.5 hrs** p not significant**P significant at <.001
Center for Studying Health System Change
Columbia University School of Nursing M6920, Fall, 2001
Managed care for uninsured*
0% 20% 40% 60%
Uninsured with difficultygetting carePersons withoutInsurancePersons in Poverty
HMO Penetration
*Center for Studying Health System Change Issue Brief #25 (Jan, 2000)
Columbia University School of Nursing M6920, Fall, 2001
HIPPA
Made insurance portable from one job to another
Limited use of ‘pre-existing conditions
Limits exclusions to conditions or treatments, if done uniformly
Cannot deny or charge more based on• health status• medical history• medical condition• claims experience• receipt of health care• genetic information• evidence of uninsurab.• disability
Columbia University School of Nursing M6920, Fall, 2001
Programs for the uninsured
Boston HealthNet & Network Health Hospitalization, OP, ER, dental, vision,
MH, pharmacy Below 200% poverty get free Enrollment 73,000 $ from state uncompensated care pool Providers paid fee for service
Columbia University School of Nursing M6920, Fall, 2001
Uninsured, cont.
Wishard Advantage, Indianapolis Hospitalization, OP, ER, pharmacy, MH Free below 150% FPL; shared up to 200%
FPL Enrollment 20,000 $56Million city/county property tax Primary care capitated $15/mo
Columbia University School of Nursing M6920, Fall, 2001
Uninsured, cont.
Ingham Health Plan, Lansing, Mich OP, pharmacy Free below 100% FPL; share to 250% Enrollment 8,500 $3.5Million from state, Medicaid, county
tax Providers fully capitated $24/mo
Columbia University School of Nursing M6920, Fall, 2001
Issues for the elderly
50% of those over 85 need assistance
Care often includes non-health components such as housing
Existing finance mechanisms not designed with these issues in mind
Columbia University School of Nursing M6920, Fall, 2001
Use of assisted living
0%
10%
20%
30%
40%
50%
Physical condition
Cognitiveimpairment
Wheelchair
Dailyincontinence
75%FemaleAverage age: F 84.5 M 82.5
Columbia University School of Nursing M6920, Fall, 2001
Practitioners decide, not patients
Older women with localized breast cancer have a choice• Breast-conserving surgery• Mastectomy
BCS used where• highest BCS fees (9x as likely)• belief in patient participation (6x)• MST favored by male surgeons
Mandelblatt et al, Medical Care 39:3 (228-242)
Columbia University School of Nursing M6920, Fall, 2001
The particular role of public hospitals*
Inclusivity Continuity Responsiveness Visibility
*Opdycke, Sandra 1999 No one was turned away: the role of public hospitals in New York City since 1900 New York: Oxford University Press
Columbia University School of Nursing M6920, Fall, 2001
Decreasing inappropriate access
shift out of emergency rooms monitoring of high-tech procedures
to limit over-use control of ownership of facilities/
equipment information about alternative
approaches
Columbia University School of Nursing M6920, Fall, 2001
Use of NYC emergency departments, 1998
42%
32%
7%
19%
Non-emergent
Emergent/PrimaryCareEmergent/EDCare/AvoidableEmergent/EDCare/Non-avoidable
Billings et al, Emergency Dept. Use: the NY Story. Commonwealth Fund: Nov. 2000
Columbia University School of Nursing M6920, Fall, 2001
Attempted use of planning
Comprehensive health planning HSA/SHCC/SHPDA Certificate of Need Push to managed plans or managed
competition