Health care system

The US health care system consists of many components, including health care payers (e.g., health insurance companies) who fund health care, health care professionals who provide health care, and patients who utilize health care. There is no universal health care coverage, and a significant number of individuals do not have health insurance. Health insurance may be funded publicly (e.g., at the federal or state level) or privately (e.g., through employers or individual purchase). Health insurance premiums, out-of-pocket costs, and flexibility to see providers outside the plan network vary by plan. Health care payers use various payment models to compensate health care organizations and providers, including traditional fee-for-service models and alternative payment models designed to increase health care quality and efficiency, such as pay-for-performance and bundled payments. Health care delivery models include traditional managed care organizations and newer models designed to improve coordination and decrease health care fragmentation, such as accountable care organizations and patient-centered medical homes.

• According to the US Census Bureau reports published in September 2020: ^[1]
  • 8% (26.1 million) of Americans did not have health insurance during 2019.
  • 92% of Americans had health insurance coverage during 2019.
    • 68% via private insurance
    • 34.1% via public insurance

Government-funded health insurance

Revisions to the Social Security Act in 1965 established public health insurance programs to provide US government funding for health care for eligible individuals.

Medicare ^[2][3][4]

Medicare is funded by the federal government.

Eligibility

• Individuals ≥ 65 years old who:
  • Are US citizens or lawful permanent residents
  • And have worked and paid Medicare taxes for a minimum of 10 years ^[4]
• Irrespective of age, individuals with any of the following may be eligible:
  • End-stage renal failure on dialysis or with a kidney transplant
  • Amyotrophic lateral sclerosis
  • Permanent disabilities ^[2]

Coverage

• The two main coverage options are:
  • Original Medicare (Part A and Part B)
  • Medicare Advantage (Part C): a private health insurance plan approved by Medicare that provides all services covered by Parts A and B ^[5]
• Prescription drug coverage options include:
  • Medicare Part D
  • Drug coverage under Medicare Advantage plans

Medicaid ^[4][8]

Medicaid is jointly funded by federal and state governments.

Eligibility ^[9]

Individuals must meet both nonfinancial and financial criteria.

• Nonfinancial
  • US citizen or lawful permanent resident
  • Residence in the state in which coverage is received
• Financial: Factors that impact financial eligibility include household income, presence of children in the home, pregnancy, disability, age, and state of residence.
  • Children and pregnant individuals living in households with income ≤ 133% of the federal poverty level (FPL) are eligible in every state. ^[10]
  • Eligibility for adults < 65 years of age with a household income ≤ 133% of the FPL is decided by each state. ^[9][11]
  • Individuals with disabilities and/or aged ≥ 65 years who receive Supplemental Security Income are generally eligible. ^[12]

The Affordable Care Act set the Medicaid household income limit at ≤ 133% of the FPL, but allowed an additional 5% of income to be disregarded, resulting in an effective limit of ≤ 138% of the FPL. ^[11]

Some individuals (e.g., individuals with disabilities and low-income adults ≥ 65 years of age) may qualify for and enroll in both Medicare and Medicaid. ^[8]

Coverage ^[13]

• Inpatient hospital care
• Physician visits
• Laboratory tests
• Radiography
• Skilled nursing care
• Home health care
• Vaccinations recommended by ACIP ^[14]
• Prescription drug coverage ^[15]

Children's Health Insurance Program (CHIP) ^[16][17]

• Funding: jointly funded by federal and state governments
• Eligibility: children living in households with low income that is not low enough to qualify for Medicaid
• Coverage
  • Hospital care
  • Well-child visits
  • Vaccinations
  • Prescription drugs
  • Laboratory tests
  • Radiography

Commercial health insurance ^[4][18]

• Used by 65% of the US population ^[18]
• May be employer-sponsored (most common), school-sponsored, or purchased individually
• Health care is delivered through networks of clinicians and hospitals.
• Plans with lower member costs generally have more restrictions on where care can be received.
  • Health insurance premiums are generally lowest for HMO plans and highest for PPO plans.
  • Out-of-pocket costs are generally higher for PPO plans than for other plans (e.g., HMO or EPO plans).

Self-pay ^[19]

• An individual who pays out of pocket for a health care service rather than using insurance (e.g., Medicare, Medicaid, or commercial health insurance), e.g., due to:
  • Lack of insurance
  • Decision to not use health insurance for a particular service
• All self-pay patients should receive an estimate of expected charges for nonemergency health care services in advance. ^[20]

Health insurance premium ^[4][21]

• Definition: a payment made to the health insurance provider, typically monthly, to maintain coverage
• Characteristics
  • The premium depends on the type of policy and individual factors (e.g., individual or family plan).
  • The deductible, copayments, and coinsurance are paid separately.
  • It can be paid by individuals and/or employers.
  • Individuals receiving insurance through their employers generally pay premiums through payroll deductions.
  • Usually, plans with higher premiums will have lower out-of-pocket expenses (e.g., deductibles) and vice versa.
    • A healthy individual who does not expect costly medical services may prefer a plan with a higher deductible and lower premium.
    • An individual who expects costly medical services (e.g., due to diagnosed medical conditions) may prefer a plan with a lower deductible and higher premium.

Out-of-pocket expenses ^[4][19][21]

• Definition: health care costs that are paid by an individual rather than by an insurance company, e.g., deductibles, coinsurance, and copayments
• Out-of-pocket maximum
  • A limit on the amount of money that an individual has to pay for covered health care services in a year (not including premiums).
  • After this amount is reached, all covered health services are paid in full by the health plan for the rest of that plan year.
  • Deductibles, copayments, and coinsurance apply to the out-of-pocket maximum.

Health insurance premiums do not count toward an individual's out-of-pocket maximum.

Deductible

• Definition: a predetermined amount paid out of pocket for health care services by an individual before the insurance company begins to pay
• Characteristics
  • Typically annual
  • After the deductible is paid, the individual usually only pays copayment and coinsurance for covered services.
• Types
  • Comprehensive deductible: applies to all services covered by the health insurance policy
  • Noncomprehensive deductible
    • Applies to specific health care services covered by the insurance policy
    • Not all health care services covered by the insurance policy have a deductible
  • Individual deductible: a deductible that applies to one person
  • Family deductible: a deductible that applies to a family of two or more individuals
    • Embedded deductible
      • Consists of both a family deductible and individual deductibles for each family member.
      • One family member cannot contribute more than the amount of the individual deductible to the total family deductible.
      • If a family member meets his or her individual deductible, the individual usually pays only copayment and coinsurance for covered services.
      • If the combined health care expenses of the family members meets the family deductible, all family members usually only pay copayment and coinsurance for covered services.
    • True family deductible
      • Members can meet the deductible by pooling health care expenses.
      • There is no limit to the amount each member can pay toward meeting the family deductible.
      • Can be met by just one member of the family or a combination of family members.
      • Once the deductible is met, all family members usually only pay copayment and coinsurance.
• Example: A $2,000 deductible means that after an individual pays $2,000 in covered medical expenses, the insurance provider will pay for the remainder of covered medical expenses during the policy period.

Copayment

• Definition: a fixed amount paid by the patient to a health service provider at the time of the service (e.g., doctor's appointment, filling of a prescription)
• Characteristics
  • Typically defined in the insurance policy
  • Paid each time the patient receives medical services
  • The amount can vary by the type of service (e.g., prescription drugs, laboratory tests).
  • Usually doesn't count toward meeting the deductible
• Example: An individual pays $20 at the time of each visit to his or her primary care provider.

Coinsurance

• Definition: a predetermined percentage of health care expenses for which an individual is responsible after meeting the deductible
• Characteristics
  • Applies to covered services
  • May be paid in addition to a copayment
• Example: If an individual has a plan with 15% coinsurance and receives a health care bill for $100 after meeting his or her deductible for the year, the insurance company will pay $85, while the individual will be responsible for $15.

Health insurance network (preferred providers) ^[4][21]

• In-network
  • A health care professional, hospital, and/or service provider who has a contract with the insurance company to provide services to plan members through a discounted fee-for-service model
  • Exclusive provider organization (EPO) and health maintenance organization (HMO) plans generally only cover in-network care, except in the case of a medical emergency.
• Out-of-network
  • A health care professional, hospital, and/or service provider who does not have a contract with the insurance company to provide services to plan members through a discounted fee-for-service model
  • Preferred provider organization (PPO) plans ; and point-of-service (POS) plans may have out-of-network care coverage.

Out-of-network copayment and coinsurance usually cost more than in-network copayment and coinsurance.

Utilization management ^[4]

• Definition: a review of the appropriateness of a provided health care service, considering factors such as cost-effectiveness and quality of care
• Examples
  • Prior authorization: a form of prospective utilization review in which health care providers must obtain approval from an insurance company in advance of a planned service (e.g., diagnostic test or treatment)
  • Concurrent utilization review: assessment of health care delivery occurring during the course of medical treatment (e.g., approval for continued hospital stay for inpatients)
  • Retrospective utilization review: assessment of health care delivery after it has already been provided to the patient to determine whether the care was appropriate

Insurance companies often require prior authorization before covering treatments for which there are concerns about cost-effectiveness, safety, and/or medical necessity. A clinician can appeal a denial of coverage if they believe the treatment is medically necessary. ^[22]

Health care payment models are generally categorized into the traditional fee-for-service model, and newer alternative payment models.

Fee-for-service ^[4][19][23]

• Health care providers are compensated by the insurer and/or patient for each individual service provided (e.g., laboratory tests, office visits, procedures).
• Dominant payment model in the US ^[24]
• May incentivize providers to overtreat patients because compensation is based on the number of services provided ^[25]
• Associated with high overall health care costs ^[25]
• Discounted fee-for-service
  • A fixed payment schedule with discounted prices for each individual service negotiated between health care providers and payers
  • Often used by PPOs
  • For health care providers, an incentive for discounted pricing is an increased number of patients through association with the payer
• Per diem payment (per day payment)
  • A fixed amount per patient per day paid to the health care provider for a specific care service provided, regardless of the actual costs involved in providing services for a particular patient.
  • Often used for reimbursement of inpatient services
  • The specific rates may vary depending on the service provided (e.g., a hospital may be paid a different rate for an inpatient stay in a medical-surgical unit compared to a stay in a critical care unit).

Alternative payment models ; (also known as value-based payment models) aim to reduce health care spending by incentivizing the delivery of high-quality, cost-conscious care over high volume of services.

• Advantages of these models include:
  • Promoting adherence to clinical guidelines and proven best practices
  • Improved delivery of coordinated and efficient care, e.g.:
    • Fewer orders for tests or procedures that are not medically necessary
    • Cost-effective preventive health care to avoid higher downstream costs
  • Increased accountability and transparency through reporting of quality metrics
• Disadvantages of these models can include:
  • Providers rejecting medically complex patients from patient panels to reduce negative impacts on the ability to meet quality metrics
  • Provision of substandard care as a method of cost reduction in models with fixed payments (e.g., capitation, global payment)
  • High administrative costs to gather data for reporting of quality metrics

Pay-for-performance (P4P) ^[26][27][28]

• Pay-for-performance models are typically fee-for-service models in which compensation also depends on health care providers meeting certain metrics for quality and efficiency of care.
• Financial incentives and penalties are tied to specific measures of quality and population health.
  • Payers require reporting of specific metrics (e.g., safety, clinical care outcomes, efficiency and cost reduction, and patient experience)
  • Data on hospital readmissions, adverse events, population health, and patient satisfaction are typically tracked.
• Examples of pay-for-performance programs administered by the Centers for Medicare and Medicaid Services include:
  • Hospital Value-Based Purchasing (VBP) Program
  • Physician Quality Reporting System (PQRS)
  • Merit-based Incentive Payment System (MIPS)

Hospital Value-Based Purchasing (VBP) Program ^[29]

This program penalizes hospitals for poor performance.

• Payments are reduced by 2% and the funds are redistributed if the provider's performance or quality of care measures are unsatisfactory. ^[29]
• Hospitals with high readmission rates for specific episodes of care (i.e., myocardial infarction, heart failure, COPD, pneumonia) may have their payments reduced by up to 3%. ^[30]
• Hospitals in the bottom quartile of performance based on certain hospital-acquired conditions (e.g., CLABSI, CAUTI, surgical site infections, MRSA, C. difficile infections) have their payments reduced by 1%. ^[31]

Physician Quality Reporting System (PQRS) ^[32][33][34]

• Definition: a reporting program; , created by the Centers for Medicare and Medicaid Services (CMS) and in place until 2017, that gave health care professionals the opportunity to assess the quality of care they were providing to their patients in order to ensure patients were receiving timely and appropriate care.
• General principles
  • Eligible health care providers: Medicare physicians providing covered professional services based on the Medicare Physician Fee Schedule (MPFS) (e.g., physicians, practitioners, therapists) could submit data about the quality of their care. ^[35]
  • Quality measures (based on STEEEP)
    • The types of measures reported changed from year to year.
    • Generally varied by specialty and focused on areas such as public health, care coordination, patient safety, clinical processes, and effectiveness
    • 254 quality measures and outcome measures were defined, for which health care providers could submit data, including:
      • Effective clinical care
      • Efficiency
      • Cost reduction
      • Patient safety
      • Communication and care coordination
  • Goal: collecting data on quality of care across health care systems
• Prior to 2015
  • Providers enrolled on a voluntary basis.
  • Participants were paid an incentive for reporting on selected quality measures based on their Medicare fee-for-service claims (i.e., participants were financially compensated for providing data).
• Between 2015 and 2017
  • Shift to a mandatory program
  • Health care professionals who did not satisfactorily submit data on quality measures, for their covered professional services, for the quality reporting period for the year would be subjected to payment adjustments for noncompliance.
  • Based on a P4P system
  • In 2017, PQRS was integrated into the Merit-based Incentive Payment System (MIPS).

Merit-based Incentive Payment System (MIPS) ^[36][37]

• Definition: a performance-based incentive program implemented by the Centers for Medicare and Medicaid Services (CMS) in place since 2017 that offers payments to eligible health care providers for high-quality and cost-effective care; aimed at improving overall health care quality, reducing costs, and increasing the use of appropriate health care information
• General principles
  • Integrates various Medicare incentive and payment programs (e.g., PQRS, Value-based Payment Modifier Program, Medicare Electronic Health Record Incentive Program) into a single system
  • Participation is mandatory for all eligible clinicians and practices (e.g., part of Medicare Part B program, previously involved in Medicare).
    • Those who fail to report are penalized financially.
      • Eligible participants can report as individuals or groups.
  • Performance measures: Reporting requirements vary for each category.
    • Quality measures
      • Providers and groups can select their own quality measures.
      • Physicians and groups must report six quality measures.
    • Improvement activities: measure of patient engagement and improvements in health care and process management
    • Promoting interoperability: an effort to make health information more available for patients, providers, and payers in order to facilitate information exchange and reduce administrative burdens across the health care system
    • Cost
      • Participants who meet the specified minimum case volume required are scored using different performance measures (e.g., total per capita cost, Medicare spending per beneficiary).
      • CMS collects this data directly from the Medicare claims data.
      • Aimed at making health care more cost-efficient and affordable
  • Participants are financially incentivized to submit data and scored according to the amount of data provided.
    • In order to achieve maximum points, participants must report sufficient data for every performance category as well as demonstrate improvements in the quality of health care and a reduction in its costs.
    • The overall score is compared to a performance threshold to determine payment adjustments.
      • Scores above the threshold: receive a payment incentive
      • Scores below the threshold: receive a negative payment adjustment
      • Scores equal the threshold: receive a neutral payment adjustment

Bundled payment ^[38]

• Health care organizations are compensated by the payer with a fixed payment for all services provided during a clinically-defined episode of care (e.g., hip replacement, cholecystectomy).
• The compensation is distributed among all health care providers involved in the care of the patient during that defined episode.
• Typically based on the estimated cost of all of the services a patient would require during a single medical treatment episode or procedure
• Example: a payment beginning 2 days prior to a knee replacement surgery and extending 30 days past a patient’s discharge from the hospital for this procedure

Capitation ^[23]

• Health care providers are compensated a fixed amount per patient by the payer during each payment period, regardless of the actual amount of health care services utilized by the patient.
• Often used by HMOs
• The payment period is usually monthly.

Global payment ^[39]

• The payer makes a single, fixed payment for the health care expenses of a population of patients (i.e., enrollees in a health plan) during a specified time period (e.g., monthly or yearly).
• Usually paid to a single health care organization
• Payments can be used for a wide range of services, e.g., physician fees, hospital services, tests, prescription drugs, follow-up visits.

Health care delivery models refer to the systems by which patients receive health care services.

Managed care organization ^[4]

• A system that integrates health care delivery and financing to provide services to a group of individuals
• Used by most private health insurance companies (see “Health care payers.”)
• Components include:
  • Shared responsibility between managed care organizations and providers to provide cost-conscious care
  • Restriction in choice of health care providers
  • Utilization management

Integrated delivery system (IDS) ^[4][40]

• An organized network that provides coordinated care across various settings for a particular patient population
• An IDS is accountable for the financial and clinical outcomes of the services it provides.
• Components include:
  • Adequate access to primary care and specialty providers
  • Reimbursement models and insurance plans that incentivize care coordination (e.g., pay-for-performance, global payment, health maintenance organizations, accountable care organizations)
  • Shared electronic health records (EHRs)
  • Promotion of a safety culture
  • Use of protocols and guidelines rooted in evidence-based medicine
  • Team-based care and multidisciplinary care models providing patient-centered care

Accountable care organization (ACO) ^[4][41]

• Network of health care providers (e.g., physicians, other clinicians, hospitals) that enroll voluntarily to provide coordinated care to a group of individuals
• Contract with different payers (e.g., Medicare; , private health insurance companies)
• Payers provide financial incentives to providers for working together to provide high-quality care at lower cost (e.g., using alternative payment models).
• ACOs are required to engage in quality improvement initiatives.

Patient-centered medical home (PCMH) ^[4][42][43]

• A team-based approach coordinated through a primary care provider aimed at providing quality, cost-conscious patient-centered care
• Components include:
  • Health care accessibility and continuity of care ^[44]
  • Comprehensive care (e.g., encompassing preventive services, chronic disease management, and acute care)
  • Care coordination across multiple providers and care settings
  • Patient-centered approach (e.g., use of shared decision-making)
  • Emphasis on high-quality care and patient safety (e.g., through quality improvement initiatives and population health management)

Just and equitable health care benefits a society as a whole by ensuring certain standards of public health that, in turn, reduce the burden of disease on the entire population. Accordingly, a health care system should strive to provide access and treatment to all population groups regardless of identity and socioeconomic status, while ensuring that underprivileged groups are not ignored.

Recognizing and addressing inequalities due to social health determinants can improve the health of the most vulnerable and at-risk groups. ^[45]

Social justice in health care

• Definition: delivery of high-quality and fair treatment, regardless of an individual's age, race, ethnicity, economic status, disability, or sexual orientation
• Types of social injustice in health care ^[46]
  • Distributive injustice: allocation of health care resources to the disadvantage of certain individuals or groups who require said resources to the same degree as those to whom they are made available (e.g., coverage of disease-modifying multiple sclerosis therapies for uninsured women but not uninsured men, who less commonly develop the disease but benefit equally from the treatment)
  • Relational injustice (identity devaluation): allocation of health care resources to the disadvantage of certain individuals or groups due to prejudice (e.g., refusing health care to individuals with limited proficiency in English)
• Measures to improve social justice in health care
  • Measures to improve distributive justice ^[47]
    • Allocate resources in ways that benefit more people (e.g., set up a budget inclusive of underserved populations).
    • Further develop distributive justice indices.
    • Foster patient relationships (e.g., involve patients in the decision-making process and emphasize their involvement in determining outcomes).
  • Measures to improve relational justice
    • Provide training to ensure health care providers are culturally competent and advocate for patient rights.
    • Create diverse care delivery models (e.g., by increasing diversity in recruiting of health care providers, on-site interpreter services, hiring staff members that speak multiple languages pertinent to the community it serves).
    • Provide virtual clinical services to enhance access to the most vulnerable groups and to facilitate scheduling (e.g., telemedicine, remote patient monitoring).
    • Allocate funds to ensure equitable care is provided to underserved populations.

Health care disparity ^[48][49][50]

• Definition: differences in health care quality and/or outcomes among specific populations due to economic, social, and/or environmental factors
• Measured by:
  • Access to health care
  • Quality of care received
• Consequences
  • Earlier onset of illness
  • Severe disease
  • Poorer quality of care
  • Reduced lifespan

Social determinants of health ^[51][52][53]

Definition

• The political, cultural, and socioeconomic conditions into which individuals are born and with which they live that have an impact on health, e.g., education, the environment, nutrition, wealth distribution, gender, race, and/or access to health care

Race and ethnicity ^[50][54]

• On average, minorities, particularly Black, Asian, and Hispanic individuals, have more limited access to health care and other community health resources. ^[55]
• Black and Hispanic individuals are more likely to report delays in receiving health care compared to White individuals.
• Studies have shown that clinicians tend to have unconscious racial bias, leading to poorer communication and lower quality of care. ^[56]

Gender roles, identity, and sexual orientation

• Members of the LGBTQ community may experience discomfort with genital, breast, or rectal exams, or when discussing sexual issues(see also “Principles of transgender health care”)
• Judgemental attitudes toward patients compromise the clinician-patient relationship and clinician's ability to provide good health care. They also discourage patients from seeking medical attention

Education

• An individual's level of education influences their type of employment and potential income, which in turn influence socioeconomic status.
• Low educational attainment is associated with: ^[57]
  • Low health literacy ^[58]
  • Negative health behaviors (e.g., cigarette smoking, lack of physical activity)
  • Poor health outcomes (e.g., increased mortality, higher incidence of chronic disease)

Health literacy ^[59]

• Health literacy refers to the ability to obtain and understand basic health information and services needed to make appropriate health decisions. ^[60][61]
• Factors associated with low health literacy include: ^[58]
  • Older age
  • Male sex
  • Racial or ethnic minority
  • Low socioeconomic status
• Low health literacy is associated with adverse outcomes, including:
  • Barriers to health care and insurance access
  • Underutilization of preventive services
  • Increased rates of hospitalization
  • Nonadherence to treatments
  • Higher mortality rates
• Clinical interventions can improve and address health literacy, e.g.:
  • If a language barrier is present, document the language preference and assess the need for medical interpretation.
  • Maintain eye contact and avoid speaking too quickly.
  • Break down information by repeating instructions in an understandable manner (i.e., use plain language instead of medical jargon or technical language).
  • Use visual aids to illustrate a procedure or condition.
  • Assess the patient's understanding of the information provided without shaming them or causing embarrassment.
  • Have the patient explain the instructions and/or demonstrate the relevant procedures themselves.
  • Provide the patient with forms and educational resources in their preferred language.
  • Offer to schedule follow-up appointments with a friend or family member present.

Socioeconomic status ^[50]

• Varies by race/ethnicity in the US
• Low socioeconomic status often involves reduced access to job opportunities and higher education.
• Income determines access to social and health resources (e.g., timely health care, preventive health care, healthy habits, food security).
• Low-income populations are more likely to be targeted by the fast food and tobacco industries, which encourage unhealthy habits. ^[51][62][63]

Housing

• Access to and/or affordability of housing (e.g., unaffordability increases the risk of homelessness)
• Environmental hazards are associated with poor housing conditions (e.g., presence of mold, water leaks, lead paint)
• Neighborhood conditions
  • Access to nutritious food, transportation, parks, clean water, unpolluted air, low crime rates, safe streets, and sidewalks
    • Food deserts ^[52][64][65]
      • Areas of limited access to healthy and affordable food (e.g., unprocessed food, especially fresh meat, fruit, and vegetables)
      • Clinicians should advocate for increased healthy food availability and provide patients with nutrition counseling based on available resources.
      • Food access should be considered when managing patients' conditions.
  • Individuals living in disadvantaged neighborhoods are more likely to have poor health outcomes and chronic conditions.

Mental health and disabilities ^[66]

• Interpersonal safety: Individuals who live in households in which family members are abusers, have committed crimes, and/or have drug and alcohol use disorders are more likely to have mental health and/or substance use disorders later in life. ^[67]
• Individuals with disabilities have more challenges accessing economic opportunities and resources (e.g., technology, fitness facilities). ^[68]
  • Negatively affects socioeconomic status and social environment
  • Leads to decreased access to health care

Addressing social determinants of health ^[51][69][70]

• Learn about how social factors influence health.
• Acknowledge and address implicit bias.
  • Look for behaviors that signal mistrust in the patient.
  • Inquire about past experiences of racism in a health care setting and acknowledge the possible harm done.
  • Treat patients with dignity and respect.
• Inquire about and seek to understand the patient's community.
  • Create a safe space for disclosure of information.
  • Evaluate a patient's mental health and social support systems.
  • Inquire about cultural preferences/norms (e.g., culturally imposed beliefs, awareness and acceptance of cultural differences, procedures and tests that go against a patient's culture).
  • Determine how the patient wants to address their health problem.
  • Inform the patient that members of the community can be present at consults.
• Establish a rapport with the local health departments and county and city health officials.
• Encourage health care teams to ask patients about their social challenges and connect patients with resources within their communities (e.g., organizations that provide financial assistance, food assistance, job placement, and training). ^[71][72]
• Develop processes that promote health literacy by presenting information clearly and adapting to the patient. ^[59]

A number of policies and models have been developed to extend and guarantee access to health care.

Emergency Medical Treatment and Labor Act (EMTALA) ^[73][74][75]

• Description: an act passed by the US Congress in 1986 that requires emergency departments in hospitals that receive Medicare funding to evaluate any patient presenting for care, and to stabilize individuals with emergency medical conditions (including labor), regardless of the patient's ability to pay for the care provided ^[76]
• Aims
  • Ensure access to emergency services for all individuals
  • Prevent the refusal of care or inappropriate transfer of care for financial reasons ^[77]
• Characteristics
  • Hospitals must evaluate any patient who presents to the emergency department with an emergency condition.
  • Hospitals must stabilize patients presenting with emergency conditions.
  • Unstable patients may only be transferred to another hospital if either of the following applies:
    • Benefits of transfer exceed the risks.
    • The patient requests the transfer.
  • Hospitals can be held liable for noncompliance. ^[77]
• Disadvantages ^[78]
  • Potential for inappropriate use of the emergency department, which can lead to:
    • Overcrowding
    • Prolonged waiting times
  • May lead to financial issues for hospitals and patients, e.g.: ^[77]
    • Inadequate reimbursement for care (e.g., if a health plan claims that treatment was not medically necessary, the condition was not an emergency, or a provider was out-of-network) ^[79]
    • Increased financial strain on smaller hospitals that need to transfer patients for more specialized care, which can lead to emergency department closures
  • The number of clinicians willing to serve on call in emergency departments has declined due to uncompensated care.

Critical access hospital ^[80][81]

• Definition: a designation created by US Congress in 1997, through the Balanced Budget Act, that is assigned to small hospitals in rural areas by the Centers for Medicare and Medicaid Services to ensure and improve access to health care services in these locations
• Aims
  • Improve health care access in rural areas
  • Provide financial support to hospitals in rural areas
• Characteristics
  • Specific requirements must be met, e.g.,
    • ≤ 25 inpatient beds
    • Located > 35 mi (> 56 km) from another hospital
    • Continuous emergency care services
  • Critical access hospitals need to maintain quality assurance and improvement with organizations or hospitals that are part of the network. ^[82]

Affordable Care Act (Obamacare) ^[4][83]

• Definition: a comprehensive health care reform law passed by the US Congress in 2010 to ensure and expand affordable, quality health care
• Aims
  • Improve health insurance affordability and access
  • Broaden state Medicaid programs to provide coverage to more individuals
  • Lower health care costs
  • Deliver high-quality care
• Characteristics ^[84]
  • Requires insurance company coverage of dependent children until the age of 26 years
  • Individuals cannot be denied health insurance based on preexisting health conditions.
  • Subsidies for the cost of health insurance, depending on income
  • Coverage for preventive care (e.g., screening studies, immunizations)
  • Expanded Medicaid eligibility in states that choose to accept funding

Assertive community treatment ^[85][86]

• Definition: an integrated treatment approach for patients with severe psychiatric conditions (e.g., schizophrenia, bipolar disorder) who are at ongoing risk of hospitalization, incarceration, and/or unstable housing
• Aim: provide resources to support community living and mental health care outside of health care settings
• Characteristics
  • Ongoing access to a multidisciplinary care team
  • Low patient-to-staff ratio (approx. 10 patients per staff member) ^[86]
  • Flexible service models to address individual patient needs
• Disadvantages ^[87]
  • Broad variability across models makes it difficult to compare outcomes
  • Funding complexity
  • Ethical concerns about limiting the patient's autonomy

Home health care ^[88][89]

• Definition: skilled care provided by health care professionals in a patient's home
• Aim
  • Treat or manage an illness or injury
  • Improve patient safety (e.g., reduce risk of falls)
  • Provide quality patient-centered care
  • Maintain patient independence, self-sufficiency, and care engagement
• Advantages
  • Lower cost than inpatient care
  • Patient comfort and convenience
  • May be eligible for Medicare coverage
• Examples
  • Skilled nursing care (e.g., for disease education, medication administration, wound management)
  • Physical, occupational, and/or speech therapy
  • Social work

Home health care may also be defined more broadly to include personal care services (i.e., help with ADLs) provided at home. These services are typically not covered by Medicare unless the patient also requires skilled care as described above. ^[88]

Fragmentation refers to a lack of integration and coordination between parts of the health care system (e.g., services of health care providers and/or organizations). ^[40][90][91]

Causes

• Reimbursement models that disincentivize care coordination (e.g., fee-for-service)
• Prioritization of individual over shared accountability among health care professionals
• Lack of communication and coordination of health records across different providers and organizations
• Increased reliance on and utilization of specialist services
• Variation in provider practice patterns

Consequences ^[4]

• Increased incidence of medical errors
• High costs for health care
• Gaps and discontinuities during transitions of care
• Increased risk of provider burnout (e.g., due to increased workload)
• Unnecessary repetition of diagnostic and therapeutic interventions

Health care fragmentation raises costs and lowers quality. ^[92]

Prevention strategies

• Coordinated health care delivery models (e.g., integrated delivery systems, accountable care organizations, and patient-centered medical homes) ^[4][40]
• Interoperable electronic health record systems ^[92]
  • EHR interoperability enables authorized individuals to generate and share protected health information within and across systems.
  • The 2009 HITECH Act was passed to encourage the adoption of EHR systems, but a lack of interoperability remains a major impediment to the integration of health care services.
  • The 21^st Century Cures Act incentivizes the use of interoperable EHR systems.
• Error prevention strategies, e.g., proper handoffs among providers between shifts, following inpatient transfers, and before patient discharge to prevent transition of care errors ^[93]

• Definitions ^[94]
  • Disability : the inability to pursue a substantial gainful activity due to a physical or mental condition that is expected to result in death or has lasted/is expected to last for a minimum of one year
  • Disability benefits: funds from public and/or private sources that are paid to individuals with an illness or disability
• Federal disability benefits: administered by the US Social Security Administration (SSA) ^[94]
  • Social Security Disability Insurance (SSDI):
    • Pays benefits to individuals with disabilities who have worked long enough and paid Social Security taxes
    • After 2 years of receiving SSDI, individuals qualify for Medicare.
    • Benefits continue until the individual can work again on a regular basis or the individual reaches age 65. ^[95]
  • Supplemental Security Income ^[96]
    • Pays benefits to individuals with a disability who have limited or no income or resources
    • Adults ≥ 65 years of age can qualify regardless of disability status.
• Disability insurance: provides a continuation of a portion of an employee's salary when the employee is unable to perform work duties due to a non-work-related injury or health condition ^[97][98]
  • Short-term disability insurance
    • Benefits usually begin 2 weeks after illness or injury. ^[97]
    • Duration of benefits is typically 3–12 months. ^[97][98]
    • Some states require employers to offer disability insurance to their employees.
  • Long-term disability insurance
    • Provides coverage for conditions that are expected to be permanent or last for years
    • Benefits may begin 30 days to 2 years after illness or injury. ^[97]
• Workers' compensation: benefits provided to individuals with work-related injuries or health conditions ^[99]
  • The employer provides insurance coverage for workers' compensation.
  • Coverage includes medical expenses and compensation for lost wages.

The US Social Security Administration does not provide disability benefits for conditions lasting < 1 year. ^[94]

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