In 1965, President Johnson signed the Medicare Social Security Amendments into law, and Medicare and Medicaid services were established in the US to provide insurance to the elderly, disabled and those with limited income. This law came after years of debate regarding the inadequacy of private insurances’ ability to provide “comprehensive, affordable health care coverage to the rapidly growing population of older adults”. More than 50 years later, the US is still struggling to develop a system that addresses the needs of the population, especially the most vulnerable.
When I started nursing school 20 years ago, I had a basic idea of how health systems operated. Very quickly it became evident that I was only working with the tip of the iceberg. Behind all day-to-day care provided is a health care system that leaves much to be desired. Insurance companies (private, Medicare, and Medicaid) make supporting patients difficult at a time when we need as many resources as possible to care for a population with increasing health needs. Patients are encouraged to seek primary care services, but there are barriers with coverage and access to care. Patients with chronic diseases need routine testing, medications, and supplies but the financial burden can be astronomical. And the sickest patients who need inpatient services (acute or long-term) have hoops to jump through just to ensure that they can be provided for, instead of being sent home unprepared and overwhelmed. During the COVID pandemic, access to care was limited and patients were more hesitant to seek care. Though Telehealth was useful in bridging the access gap, delay of care ramifications will need to be studied over time to determine the true impact.
The World Health Organization (WHO) Constitution recognizes that “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” and that all people have a right to that state of well-being. As health care has developed over the years, there has been increased emphasis in studying the factors that contribute to overall health, including genetics, health behaviors, social circumstances, environmental/physical influences and medical care. Understanding these areas is essential to understanding a person’s overall health and/or barriers to optimal health.
Once the health needs and determinants of health are established, processes must be put into place to be able to address the outstanding issues. According to Goldsteen et al1(p18) the six components of health care systems – facilities, workforce, medical products, leadership and governance, financing mechanisms and information systems – are developed to center around the needs of the population served. Internally, focus on staffing, burnout, education, and professional development will bolster a part of the workforce that has been overwhelmed in the last few years. Financial considerations allow health systems to continue to operate but must be balanced with the needs of the community, population, and workforce. Leadership is key in making decisions that can help sustain and grow capabilities, rather than limiting the type and amount of care given to the community.
Outwardly, each health care delivery system must be able to tailor the care that is offered around providing high quality service at an affordable cost. As insurance plans move away from fee-for-service and toward value-based payment models, providing equitable care to all populations will need to be intentional in order to address the various disparities and determinants of health. Availability of resources for people in the community is essential to addressing the barriers and determinants that drive the success of both wellness and disease management. Special programs1(p24) for certain disease states or populations can be critical to the success of health management.
If the present state of the US Health System is designed to focus on the “whole” patient, then the consideration of health behaviors, determinants of health and equity of care is critical to this success. Health systems must be able to prioritize the needs of the community, but to do so requires support from insurance companies, Medicare and Medicaid. As we move into the future, the success of our health care system will be dependent upon whether we are able to not just sustain, but grow, in our ability to care for all.
- Goldsteen R, Goldsteen K, Goldsteen B. Jonas’ Introduction to the US Health Care System. Ninth Edition. New York, NY: Springer Publishing; 2020.
Thank you for an excellent synopsis of the present healthcare system. As you mentioned, the healthcare system is moving much more to value-based care. Value-based care is essentially providing low cost care that generates improved outcomes for patients. Outcomes can be interpreted differently by providers and patients. For example, providers are encouraged to discharge patients home with home health support with goal of shortening hospital stays which can cost up to $4,000 per day. Patients and families often feel unprepared to go home especially if they have limited resources. As a result, patients and families are providing much more complex medical self care which may provide value to the health system but not always viewed as value by the patients. In my surgical oncology practice, we are very focused on managing sick patients in the outpatient setting as much as possible. This care adds additional stress to the health system as we add “add-on” imaging studies into routine scheduled patients which adds delays to our healthy patients. As the sick patients are managing more advanced self medical care, healthy patients are impacted and neither group sees any value in their care. We as providers are fielding the frustrations of the patients directly. Many question our clinical skills in managing their illnesses, become angry when we cannot admit them to the hospital. We leave the exam rooms and enter our workrooms to try to process the moral injury. Our moral injury is that we too are limited with our options. We sometimes know we need admit our patient to the hospital but we cannot because no bed available, cannot send to the emergency room because it is also overflowing. I think my primary point with my commentary here is through all of the judgment of the healthcare system, cost, and expense, the providers and clinical staff are highly vested in providing quality care but are also working within the same constraints of healthcare funding sources in the same way that our patients are. We are equally frustrated by the level of expense of healthcare and our lack of direct input to it.
Hi Kara,
I hate to read to your comments about your frustrations. It is so hard to see our providers, nurses and extenders and physicians, who want to do all they can, know what needs to be done but physically can’t. It takes a toll on you mentally and physically. It is hard not to take this burden home with you as well. The wait times in the ED are outrageous. I think every day I am at work we hear the announcement facility response capacity red. We do not have enough staff and enough rooms to help everyone. I truly hope this class, and everyone’s perspective helps us understand what needs to be done to help this situation. I say it a lot, but I think the crisis we are going thru right now as a health care system is worse than during COVID and the year 2020.
Hi Kara, thank you for sharing your perspective. I certainly see that level of frustration by healthcare providers and staff on a daily basis. While my initial post was tailored to the system itself, my everyday view is from the space between the providers, patients and system. We strive to provide high quality value-based care, but you are correct that each stakeholder will view that in different ways. We want patients to have the best, most efficient care but the ins-and-outs of that are far more complex than what they may see or understand. It’s always sad to see when that frustration is taken out on providers and staff, who are truly working as hard as possible to provide care. Thank you for your work, and for sharing your experience. My hope is that, as we move forward, more resources will become available for patients as well as for healthcare providers, to ease some of those frustrations for everyone.
Thank you Layne for summarizing the first chapter of the book, it is incredibly helpful for me to be exposed to numerous perspectives. I am very new to health care and in a short time had some great experiences. I spent the last year or two working in 3 different temp positions in Duke Chancellor’s team, Duke Benefits team, and now my FT positions at UNC Health with the Gastroenterology Team. I feel my exposure to the different offices has shown me how much planning and integration it takes to really get the ball moving. In relation to Chapter 1 I can see how it is a maze of decisions and implementation to get care to patients. Part of the reason I kept trying different experiences is because I was interested in the process of how patient get care and how quality is maintained. More importantly how does a decision from the top effect the employees in the hospital. In the short time I was at Duke I was able to sit in on meetings with nurses and hear their Idea’s on how to improve patient care and expanding patient resources. I like that multiples teams where coming together to work on collaborating. I do think that there is truth to creating health resources around the community it serves and I am very interested in learning about the finances behind all the moves that need to be made. As some who has not worked directly with patients I can only imagine the navigation it takes to interpret insurance, resources, preventably care, and care when a patient goes home. The one thing that inspires me is thousands of people are working everyday to keep this wheel turning and I hope that I can play a small role in that.
Kara I like your perspective and knowledge on what patients and families are experiencing when they leave the hospital. I am curious how adding care outside of the office is impacting the staff that works in these facilities and if there are enough people to do this without being burnt out. I am a very outside perspective because I have never worked in a medical office with patients and I would love to learn more about the frustration and the finances that come with it.
Nina
Layne,
Thank your detailed response to Chapter 1. I love to read everyone’s perspective from their personal profession and how it affects them. You stated that access was limited, and people were less inclined to come seek treatment during COVID. I wonder if what we are seeing now, is directly related to that. That is everyone put off care and treatment they needed, and they are seeking it now and, in many cases, the symptoms or disease is worse. One symptom they may have been experiencing, after waiting a year to be seen now affects the “whole” patient. It then could affect their health behaviors; mentally and physically.
I also think now that everyone is seeking treatment, there is more of a demand for the hospitals, outpatient facilities and primary care offices. I know in Chapter 3 we start reading about burnout and loss of our medical staff, and that is very accurate for this season we are in. More people are seeking help, but we lost a lot of staff including nurses, PA’s and NP’s and physicians. Demand vs Supply in short terms. I am very curious to see what staffing looks like for 2023.
-Holly
Thanks all for your contributions to the conversation about the present state of our health care system as described by Layne and responded to by Kara, Janina, and Holly.
A common theme in the comments is the state of burn out that has deeply and negatively impacted staffing levels. As a result, there are bigger holes in our health care safety net. I suspect the understaffing problem predates COVID and once the pandemic hit it stressed our system and many good people beyond coping. This stress was also caused by questionable resource allocation decisions. For example, many hospital enterprises had been downsizing their less used pediatric bed complement and then found themselves woefully unprepared for the RSV surge we experienced this winter. Of course, it is difficult to “plan” for a pandemic or crisis but then again it is the job of health care planners to build good contingency plans that can be implemented when the need arises. One has to wonder just how well the health care and public health sectors coordinated their roles in preparing to act in the event of our recent health care emergencies. A few of you cited the need for good leadership in these cases.
PDB
Hi Layne,
Thank you for your response. Similarly, when I began working in the healthcare world and learned about healthcare insurances, I was only scratching the surface of how it all worked. I used to work at the hospital in Fayetteville, NC and had to interview ER patients who came in for car accidents or workers comp injuries. It was amazing to me how many were uninsured and had underlying health conditions they were not seeking treatment for because of being uninsured and high medical costs. I like that you brought up COVID. Unfortunately, this pandemic has exposed the US healthcare system as a whole, as well as the most vulnerable populations. Progressive action towards delivery equitable healthcare is very much needed. As you stated, “Availability of resources for people in the community is essential to addressing the barriers and determinants that drive the success of both wellness and disease management.” This cannot be stressed enough. As barriers and determinants of health is something we discuss a lot in Public Health, it is so important to peel back the layers to see how everything is connected from a communities lack of resources, being linked to health outcomes, lack of insurance, and so on. Very detailed post, I enjoyed reading it!