Lesson

Last week, we learned a few things related to the evolution of healthcare services in the United States, with a focus on hospital services and the use of technology and information systems in healthcare. We also explained the role of health information technology and how we interact with other healthcare professionals to perform our tasks.

This week, we are continuing the discussion of healthcare services, and the focal point will be the impact of the federal government on healthcare delivery and forces affecting healthcare services. We will also “zoom in” on hospital operations and learn more about other types of healthcare settings and some aspects of healthcare reimbursement.

Cost and access to healthcare services have been concerns for almost a century in the United States. Although the government had discussed the issue, there was not much action taken until the late 1920s and early 1930s. In 1929, Baylor University Hospital in Dallas started offering healthcare services to school teachers in exchange for a low monthly fee. During the Great Depression, this concept was adapted and further developed into prepaid health plans for hospitals, a plan known today as Blue Cross. Blue Shield plans grew from that idea to prepay physicians for their services. Later, the government started to pay for some healthcare services and some physicians were willing to accept government-sponsored health insurance. The idea of national healthcare has been around since the late 1940s. So far, we have the Medicare program for older adults and Medicaid for individuals and families with low incomes.

Many acts of federal legislation have influenced the healthcare delivery system in the United States during the 20th century. These include the Biologic Control Act of 1902, Social Security Act of 1935, Hospital Survey and Construction Act of 1946, Public Law 89-97, Public Law 92-602, Health Planning and Resources Development Act of 1974, Utilization Review Act of 1977, Peer Review Improvement Act of 1982, Tax Equity and Fiscal Responsibility Act of 1982, public law 98-21 of 1983, Consolidated Omnibus Budget Reconciliation Act of 1985, Omnibus Budget Reconciliation Act of 1986, Health Care Quality Improvement Act of 1986, Omnibus Budget Reconciliation Act of 1989, Omnibus Reconciliation Act of 1990, Health Insurance Portability and Accountability Act of 1996, and HITECH Act of 2009. All of these acts have helped to shape the healthcare system we have today. The following timeline summarizes some of these important federal steps in improving healthcare over the years.

Accreditation and certification are synonymous with quality. When an organization has met accreditation or certification, it has met the reviewing organization's minimum requirements. The Joint Commission (JC)—formally known as Joint Commission on Accreditation of Healthcare Organizations (JCAHO)—and American Osteopathic Association (AOA) are volunteer organizations used to measure and ensure the quality of healthcare organizations. The Joint Commission is a private, nonprofit organization that has established guidelines and standards for high-quality operation and management of healthcare organizations. Its mission and purpose is to measure and ensure the quality of healthcare services. Once a facility has been accredited, it is considered to have "deemed status" and does not need to be inspected by Medicare. This status enables the healthcare facility to treat Medicare and Medicaid patients and receive reimbursement for the services rendered from these federal and state programs. Accreditation is important and valuable, but it is voluntary. Healthcare facilities choose to become accredited and certified.

On the other side, each state has a separate set of standards that must be met before healthcare organizations are given permission to operate. This process is conducted and monitored by the state's Department of Health and is called licensure. Licensure is mandatory. Although the standards will be different in each state, their ultimate goal is the same: to ensure that the health and safety of patients are maintained.

Hospitals in the United States vary from large, with over 500 beds, to small, with fewer than 100 beds. They also vary by the type of services provided, patient population served, type of ownership, and whether they are for-profit or not-for-profit.

Can you identify some of the hospitals in your area? Are they large or small? Are they general hospitals or specialty hospitals? Do you know who owns them?

A hospital is generally organized to meet the needs of the patients served, but there are some typical structures that deserve attention: board of directors, medical staff, nursing or patient care services, administrative staff, diagnostic and therapeutic services, and other types of support services.

Hospitals are not the only healthcare service. Today, healthcare is delivered in physician's offices, ambulatory surgery centers, emergency centers, subacute facilities, rehabilitation facilities, nursing homes, pharmacies, public health offices, assisted-living residences, adult daycare centers, and even patients' homes. Technology has made it possible for many services traditionally offered only in hospitals to be offered in ambulatory care settings. This vast offering of services has increased access and provided a good response to the changing needs of our population. For example, a patient suffering with end stage renal disease who is otherwise stable can choose to perform dialysis at home where he or she feels more comfortable.

In addition, the large variety of healthcare services enables better use of resources and helps control healthcare costs. For example, it usually costs more to provide services in an emergency room than in a physician's office. A patient with a common cold can see a family practice doctor and start treating the cold right away without having to go to an emergency room, thus avoiding the unnecessary cost.

As you progress in the HIT program, you will take a separate course that explains all the details of healthcare reimbursement in the United States. For now, know that there are two common ways to pay for healthcare services: government-sponsored and managed-care systems. The government-sponsored programs include Medicare; Medicaid; services provided to government agencies, such as TRICARE, Department of Veterans Affairs, and Indian Health Services; and worker's compensation. Managed-care systems, on the other side, include all the healthcare plans that are prepaid by individuals or employers. They are arranged in a number of ways, from health maintenance organizations (HMOs) to preferred provider organizations (PPOs).

With the new healthcare reform of 2010, we may see changes in the way healthcare is reimbursed. To review updates of the healthcare reform, visit the Department of Health and Human Services website (http://www.hhs.gov/).

As discussed above, federal legislation has significantly changed the way healthcare services are delivered, standardized, and monitored. As a result, healthcare quality has improved over the years, life expectancy has increased, mortality rates have gone down, and we have been able to control and prevent various infectious diseases and other life-threatening epidemics. Take a look at the Centers for Disease Control and Prevention website (http://www.cdc.gov/nchs/fastats/lifexpec.htm) and check out some facts. What do you think? Is this evidence that healthcare quality has in fact improved over the years?

Along with healthcare quality comes an increase in healthcare costs. According to the Bureau of Economic Analysis, healthcare expenses rose 5.6% in the fourth quarter of 2013 (Davidson, 2014). The fourth quarter of 2013 proved to show the fastest healthcare spending rate since 2003 (Davidson, 2014).

Are there any other factors that have affected and continue to affect healthcare in the United States? Sure! Think about the demographic trends, population growth, and increased diversity within the nation. For example, as life expectancy goes up, people are living longer, which means that there is going to be a growing need for healthcare services. Perhaps more long-term care or home healthcare services may be needed. What do you think?

Think about some of the healthcare technologies available and how they are used in treatment and care. For example, laparoscopic surgery has shortened healing time and many procedures, such as a gallbladder removal, can now be done within a day, without the need for hospitalization. How will these technologies impact healthcare delivery?

Advanced medicine has reduced mortality rates from certain diseases, but patients living with such diseases still have to manage these chronic conditions. How will this impact healthcare delivery?

Economic pressures and rises in costs, as well the efforts to be patient-centered, have prompted integration among various healthcare facilities. For example, a hospital, a nursing home, and a number of physician practices can join their resources and create a healthcare system. An integrated healthcare delivery system provides more comprehensive services to patients and a better continuum of care. So, a patient seen in a physician's office can be followed up with at the hospital for acute care needs, then transferred to a skilled nursing facility for long-term care. The fact that these three types of services are administered by one system means quicker decision making and arrangements for admission and care. Do you know of any healthcare systems in your local area? What are they comprised off?

Last but not least, what does this all mean for us as future HIT professionals? Well, when more healthcare services are needed and provided, more patient data and records will be produced, so we need to be able to manage larger amounts of health information. New developments in technology, communications, and information systems mean that we must understand more systems in order to improve speed and accuracy of data processing and analysis and to use the data for quality improvement. Cost pressures underline the need to explore the most efficient ways of performing all these activities.

During George W. Bush's presidency, his administration started the testing of the agenda for the health information exchange (HIE). There are three primary types of HIEs, which include the federated model, the centralized model, and the consistent federated model. The purpose of the HIE is to provide health information electronically across organizations, which allows for better patient care.

The federated model does not have a central location of data and could be considered the most secure model of HIE; however, there is a possibility of not locating all of the patient information needed. As the consolidated model's name implies, there is central storage of data in one large database. The consistent federated model has some of both the federated and the consolidated models, where the data are central but are physically and logically separated.

The Accountable Care Organization (ACO) was proposed by the Affordable Care Act of 2010. The ACO is a group or network of hospitals and physicians who share the responsibility of providing care to Medicare patients. An ACO's purpose is to try and help save money by working together as a team in treating Medicare patients. Quality has to be met in five key areas in order to share in savings: care coordination, patient and caregiver care experiences, patient safety, preventive health, and at-risk population or frail older adult health.

Davidson, P. (2014, April 1). Healthcare spending growth hits 10-year high. Retrieved from http://www.usatoday.com/story/money/business/2014/03/30/health-care-spending/7007987/