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?