The government regulates many aspects of health care. Public policy determines how much money the government pays for health care and what services they provide. The judicial branch decides when hospitals or groups of health care professionals are engaging in illegal anticompetitive practices. The executive and administrative branches are responsible for developing rules and regulations and implementing health care programs. Public and private sectors work together closely to influence health care policy, but their roles are often unclear and change over time.
Although more people have health insurance today than in the past, many are still lacking coverage for basic preventive care. In 2008, only three-quarters of adults with employment-based health insurance received an adult physical exam. In 2000, ninety percent of these adults were covered by health insurance plans. The type of health plan a person has determines whether or not a specific medical service is covered. In general, traditional indemnity plans offer the least comprehensive coverage.
Health care has evolved into various levels, or specialties. Primary care involves seeing a primary health care provider for minor injuries and illnesses, as well as screenings. Secondary care, on the other hand, requires a physician to treat patients in more complicated and complex conditions. The latter level requires specialists, such as oncologists and cardiologists. Further, quaternary care extends this level of care and is more specialized. The quaternary level is rare.
Implementing the value agenda requires a shift in clinical organization. The first principle of structuring any business is to organize around the needs of the customer. In health care, this means transforming from a siloed organization to a patient-centered one. This shift can be achieved by developing an integrated practice unit, which consists of nonclinical and clinical personnel. Further, this shift can also result in the elimination of redundant and unproductive services.
The process of quality improvement can be improved by measuring outcomes. Quality measures can be grouped according to medical conditions and should follow patients from their diagnosis through treatment. The outcomes should be standardized and cover the complete care cycle. The health care providers should measure patient functional status, mortality rates, and the impact of care on the patient’s quality of life. The HEDIS scores are designed to capture the compliance with practice guidelines. For example, providers of diabetes care measure the reliability of LDL cholesterol checks and hemoglobin A1c levels. Patients care about the possibility of vision loss, dialysis, and amputation.
Despite the growing emphasis on measuring patient outcomes and costs, health care reform has stalled due to lack of clarity regarding its goal. The pursuit of narrow goals has distracted attention from the more important objectives, such as improving patient access and reducing costs. The focus on improving patient outcomes has never been aligned with the profits of health care providers. The cost-benefit ratio does not seem to change. As a result, the quality of care does not improve.