Category Archives: Society

Immunization and Infectious Disease Mitigation

Cultural Models of Immunization and Infectious Disease Mitigation

The members of some communities, such as Puerto Rico, do not understand the scope and severity of some infectious diseases until they become infected (Pérez-Guerra, Zielinski-Gutierrez, Vargas-Torres, & Clark, 2009). The lack of a basic understanding of illness and infection poses a roadblock to mitigating disease transmission within the community. For Pérez-Guerra et al., the perception of severity and mitigation is important as they investigate the difference in attitudes towards dengue infections because dengue cannot be controlled by vaccine and must be mitigated by community participation in mosquito abatement activities. Other infectious diseases, however, can be controlled by vaccine, but efforts to limit infection are met with ignorance or misconceptions (Lau, Griffiths, Choi, & Tsui, 2010; Leask, Sheikh-Mohammed, MacIntyre, Leask, & Wood, 2006).

Public health officials, in concert with community leaders, should seek to educate affected communities about the infectious diseases they face along with effective mitigation strategies and the importance of vaccination, if available. Coreil (2010) describes the importance of cultural models in “[gaining] a deeper understanding of the cultural context of behavior” (p. 83). If behaviors are not understood, then it will be difficult to redirect them. Reaching out to community leaders has the added effect of allowing the leaders to alter the message just enough so that it might be effectively communicated to the community.

Providing a cultural health model allows for a larger scope of audience while effectively tailoring the message so that most of the target audience will appreciate the nature of the message. Approaching health behaviors from a cultural stand-point also offers the advantage of allowing peer support to propagate messages through out the community. This might be especially true when dealing with a multitude of subcultures where the message might better be disseminated via interpersonal means. Eventually, the message will be received by many individuals who will begin to have discussions with others in the community. For communities where individuals are not likely to speak to each other regarding personal health-related matters, the cultural health model allows a general message to reach each individual.

References

Coreil, J. (Ed.). (2010). Social and behavioral foundations of public health (2nd ed.). Thousand Oaks, CA: Sage.

Lau, J. T. F., Griffiths, S., Choi, K. C., & Tsui, H. Y. (2010). Avoidance behaviors and negative psychological responses in the general population in the initial stage of the H1N1 pandemic in Hong Kong. BMC Infectious Diseases, 10(139), 1-13. doi:10.1186/1471-2334-10-139

Leask, J., Sheikh-Mohammed, M., MacIntyre, C. R., Leask, A., & Wood, N. J. (2006). Community perceptions about infectious disease risk posed by new arrivals: A qualitative study. The Medical Journal of Australia, 185(11/12), 591-593. Retrieved from http://www.mja.com.au/public/issues/185_11_041206/lea10999_fm.pdf

Pérez-Guerra, C. L., Zielinski-Gutierrez, E., Vargas-Torres, D., & Clark, G. G. (2009). Community beliefs and practices about dengue in Puerto Rico. Pan American Journal of Public Health, 25(3), 218-226. doi:10.1590/S1020-49892009000300005

Living Longer and Happier Lives

As we age, we tend to question our mortality and how much longer we have left to live. Not that we can do much about this in order to extend our lives by this time, but if we question our health earlier, we may be able to affect positive change in order to have a longer and more productive quality of life. Dan Buettner (National Public Radio [NPR], 2008; TED, 2009) discusses how difficult it can be to control the effects of aging, but he also offers some options based on his observations of what are termed blue zones. Blue zones are geographic and cultural areas of the where people tend to live longer and healthier lives.

Buettner (NPR, 2008; TED, 2009) describes simple measures that can contribute to increasing a productive life. More importantly, he has uncovered what they do not do. The people who live in these blue zones, according to Buettner, do not tend to take daily supplements, pills, or extracts. Instead, continuous and simple movement for exercise coupled with a sensible cultural diet seems to have the biggest impact.

One of the observations that I have made over the years is that as physical movement declines, physical and emotional strength wane. For example, an otherwise healthy 70 year old woman who accidentally falls and breaks her hip decreases her life expectancy drastically unless physical rehabilitation is utilized to regain her activity level (Keene, Parker, & Pryor, 1993; Lyons, 1997). It is vitally important to maintain a healthy level of activity throughout life.

Diet is very important. Buettner (NPR, 2008; TED, 2009) credits adding nuts to the diet for an average increase of three years of life. The way in which our bodies use energy is very important, and we must supply it with a fuel that is efficient. A wholesome diet, I believe, is the best diet, especially if divided by five or more meals a day.

We cannot have a conversation about improving overall health without addressing some of the unhealthy vices that we tend to indulge in. Instead of outlining each and every thing that is detrimental to our health, I will say that moderation should be the way to combat the effects of vices. We need to enjoy life, and I feel that the mere enjoyment leads to a longer and healthier life; therefore, to strictly limit indulgences would seem to be counter-productive. Moderation should certainly be the way in which to address these issues.

We all want to live longer and healthier lives, but genetics does play a role. There are some aspects of our lifestyle that we are finding that we can change for the better, and the alternatives are not that bad. So long as we live healthy lives, we can enjoy life more completely.

References

Keene, G. S., Parker, M. J., & Pryor, G. A. (1993). Mortality and morbidity after hip fractures. British Medical Journal, 307, 1248-1250. doi:10.1136/bmj.307.6914.1248

Lyons, A. R. (1997). Clinical outcomes and treatment of hip fractures. American Journal of Medicine, 103(2), S51-S64. doi:10.1016/S0002-9343(97)90027-9

National Public Radio (Producer). (2008, June 8). Can ‘blue zones’ help turn back the biological clock? [Audio podcast]. Retrieved from http://www.npr.org/templates/story/story.php?storyId=91285403&from=mobile

TED (Producer). (2009, September). Dan Buettner: How to live to be 100+ [Web Video]. Retrieved from http://www.ted.com/talks/dan_buettner_how_to_live_to_be_100.html

Social Ecology of Immunization and Infectious Diseases

Vaccines are very useful as preventive medicine in public health to reduce morbidity and mortality due to communicable diseases, though they are not a substitute to safe drinking water, sanitation, nutrition and environmental health in the long run.
(Madhavi et al., 2010, p. 618)

In dealing with infectious diseases, two primary methods of prevention are worthwhile: immunization and avoidance. Avoidance is nearly impossible as valence for various pathogens vary so greatly and community network structure influences (Ciccaroneet al., 2010; Salathé & Jones, 2010). Immunization, on the other hand, allows for proximal contact with a specific pathogen without the likelihood to effective transmission, or active infection. Immunization, or innoculation, is the process of introducing the immune system to potential future pathogens so that it may form lifelong antibodies that can readily attack the pathogen if infected in the future (Centers for Disease Control, 2009). Immunization is gaining stronger support in the face of a growing number of antibiotic-resistant pathogens and pathogens with a propensity for recombination under heavy environmentally selective pressures, and though antibiotic therapy is a reliable and effective secondary prevention method, it seems to be true that antibiotic therapy is becoming less effective the more we rely on it as a prophylaxis (Laxminarayan & Brown, 2001). Additionally, antibiotics are only effective in the treatment of bacterial infections and have no effect on viral infections. Antiviral medications are typically more expensive and less available.

Luckily, when speaking about infectious processes, there is little need for continuous care after the acute presentation (Ciccarone et al., 2010). The pathogen is typically eradicated from the host by means of the natural combative effects of the immune system in combination, when required, with pharmacological assistance, and there is only a small chance of the host suffering any lasting effects. Unfortunately, there are some pathogens that continue to cause harm well after the acute phase of infection. Pathogens, such as the human immunodeficiency virus, ravage the immune system making the host susceptible to a number of other opportunistic infections that can become life-threatening. Other pathogens, such as hepatitis, can damage the natural filtration system of the host’s body that other deleterious effects surface creating a chronic disease process of the organs. In these, and other, cases, tertiary prevention strategies can help to offer the host a meaningful quality of life with the presence of the disease process. Some effective tertiary methods include medications aimed at improving the function of certain organs or systems. Diet and exercise also plays a major role in tertiary prevention strategies (Stokols, 1992).

Depending on the particular pathogen, infection might not affect me as much as others. As a paramedic, I have a comfortable knowledge of infectious disease processes, and I understand that a simple regimen of antibiotic medication, along with rest and fluid intake, will cure most of the infectious bacterial diseases that I might face, albeit some drug-resistant pathogens are not so easy to manage. Additionally, I have isolation equipment at my disposal that allows me to create a barrier from these and other infectious diseases. Ciccarone et al. (2010) further describe many of the psychosocial barriers Asian and Pacific Islanders face when confronted with the early stages of some infections. “Psychosocial issues such as depression, embarrassment, and shyness were reported to have influenced time to seeking medical attention” (Ciccarone et al., 2010, p. 143). Although I accept that I may suffer one or more of these barriers, my education, along with mandatory workplace reporting requirements, empower me to seek medical care when needed.

Addressing prevention strategies, Stokols (1992) introduces a model using the social ecology of health. Though he does not categorize primary, secondary, and tertiary means, he does hint at prevention strategies being proximal or distal. Further, Stokols outlines a variety of means related directly to an understanding of environmental roles and pressures. Understanding how an individual relates to, from, and within his or her ecology allows the health practitioner to provide more focused means of prevention and education.

References

Centers for Disease Control. (2009). Parent’s Guide to Immunizations [Excerpt]. Retrieved from http://www.cdc.gov/vaccines/vac-gen/downloads/pg_how_vacc_work.pdf

Ciccarone, R. M., Kim, M., Tice, A. D., Nakata, M., Effler, P., Jernigan, D. B., … & Sinkowitz-Cochran, R. L. (2010). Prevention of community-associated methicillin-resistant staphylococcus aureus infection among Asian/Pacific Islanders: A qualitative assessment. Hawai‘i Medical Journal, 69(6), 142-144. Retrieved from http://web.ebscohost.com.ezp.waldenulibrary.org/

Laxminarayan, R. & Brown, G. M. (2001). Economics of antibiotic resistance: A theory of optimal use. Journal of Environmental Economics and Management, 42(2), 183-206. doi:10.1006/jeem.2000.1156

Madhavi, Y., Puliyel, J. M., Mathew, J. L., Raghuram, N., Phadke, A., Shiva, M., … & Banerji, D. (2010). Evidence-based national vaccine policy. Indian Journal of Medical Research, 131, 617-628. Retrieved from http://web.ebscohost.com.ezp.waldenulibrary.org/

Salathé, M. & Jones, J. H. (2010). Dynamics and control of diseases in networks with community structure. PLoS Computational Biology, 6(4), e1000736. doi:10.1371/journal.pcbi.1000736

Stokols, D. (1992). Establishing and maintaining healthy environments: Toward a social ecology of health promotion. American Psychologist, 47(1), 6-22. doi:10.1037/0003-066X.47.1.6

Reducing Philanthropy to Political Commentary

In searching the typical news outlets for stories related to health care reform, be it local or national, I cannot help but notice that health care reform is the news. The factions are split, and the bias is evident. As the news outlets lean more to the left of the political spectrum than ever before, it is almost impossible to research the real issues at hand. Wading through the political views to glimpse a meaningful patient-focused agenda is quite difficult lately.

An article written by Randall Beach (2009) of the New Haven Register focuses on a group of doctors that rely on charity to provide health care to a select adult population who do not qualify for Medicaid and make less than $20,000 per year. Unfortunately, this article, like so many others, reduces philanthropy to political commentary.

Our current health care system is fragmented, and many people believe health care reform is needed (“54% Say Major Changes Needed”, 2009). As Dr. Peter Ellis is quoted, “Our motto is: ‘Health care reform starts at home'” (Beach, 2009, p. 3). It does not make sense, however, to provide Universal Health Care at the cost of our failing economy. Dr. Ellis’ group, Project Access, has secured funding from private sources, including the Hospital of St. Raphael and Yale-New Haven Hospital staff, the Aetna Group, the Community Foundation for Greater New Haven, and the New Haven County Medical Association Foundation. Additionally, 350 local care providers are associated with the project. This is a grassroots effort at helping to care for our neighbors, and as far as I have read, it seems to be a reasonable and responsible attempt to mend some of the local disparities to health care access.

Though I commend Mr. Beach for covering such a newsworthy story, it serves no one to inflame the current health care debates with political posturing by the media. I believe that the recent passing of health care reform will do nothing but create more clutter and complication for us to untangle when we finally have the financial stability to address the issue responsibly and realistically. In the meantime, I, like Project Access, will continue to volunteer my time and medical services to my community.

References

Beach, R. (2009, December 28). Doctors giving health care reform a head start. New Haven Register. Retrieved from http://www.nhregister.com/articles/2009/12/28/news/new_haven/a1_mon_nedoctors_art.prt

54% Say Major Changes Needed in Health Care System, 45% Disagree. (2009, October 2). Rasmussen Reports. Retrieved from http://www.rasmussenreports.com/public_content/politics/current_events/healthcare/october_2009/54_say_major_changes_needed_in_health_care_system_45_disagree

Health Care Reform

In beginning this endeavor, I found it initially difficult to find anything related to health care legislation that I would be inclined to support or oppose in a letter to my Congressman. I tend to rely on the elections in order to convey my political positions. After studying some of the recent legislation, I found that the only premise that interested me was the adoption of The Patient Protection and Affordable Care Act of 2010 and the related Health Care and Education Reconciliation Act of 2010. Unfortunately, attempting to find credible dialogue on the internet regarding these laws is both impractical and near impossible. The special interest groups are leaning to their respective extremes. With commentary not proving trustworthy for factual insight, I relied on the Congressional Budget Office and the full text of the laws to cement my position. Using the aforementioned information in conjunction with Senator Lieberman’s contact information from the U. S. Senate website (http://www.senate.gov), I formulated a letter to him outlining my economic concerns (see Appendix).

I understand the grandeur of the idea of universal health care. I applaud the debates of how best to offer affordable or free health care to ever citizen of the United States. Unfortunately, as a nation, we are not fit in our financial means to proffer such an expensive entitlement. As Goodson (2010) reports, many of the initiatives outlined within the law are not guaranteed to be successful. This at an increased cost of $390 billion over the first 10 years (Elmendorf, 2010).

To ensure that my points were valid, I researched the approval ratings of these laws. According to WashingtonWatch.com (2010), approximately 80% of respondants do not favor the passing of these laws. More scientifically, however, a consistent range of 54 – 58% of Americans favor repeal of the laws, while 63% of senior citizens agree (Rasmussen Reports, 2010).

References

Elmendorf, D. W. (2010, March 20). Manager’s amendment to reconciliation proposal [Letter to the Honorable Nancy Pelosi]. U. S. Congress, Washington, D. C. Retrieved from the Congressional Budget Office website: http://www.cbo.gov/ftpdocs/113xx/doc11379/ Manager%27sAmendmenttoReconciliationProposal.pdf

Goodson, J. D. (2010). Patient Protection and Affordable Care Act: Promise and peril for primary care. Annals of Internal Medicine. Advance online publication. Retrieved from http://www.annals.org/content/early/2010/04/15/0003-4819-152-11-201006010-00249.full

Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152 (2010).

Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148 (2010).

Rasmussen Reports. (2010, May 17). Health care law: 56% Still Want to Repeal Health Care Law, Political Class Disagrees. Retrieved on May 22, 2010, from http://www.rasmussenreports.com/public_content/politics/current_events/healthcare/march_2010/health_care_law

WashingtonWatch.com. (2010). P.L. 111-148, The Patient Protection and Affordable Care Act. Retrieved on May, 22, 2010 from http://www.washingtonwatch.com/bills/show/111_PL_111-148.html

Appendix

Michael F. Schadone
[REDACTED]
Woodstock, CT 06282

The Honorable Joseph I. Lieberman
706 Hart Office Building
United States Senate
Washington, DC 20510

May 22, 2010

Re: The Patient Protection and Affordable Care Act of 2010

 Dear Senator:

 My name is Michael Schadone and I am a nationally registered critical care paramedic working in Northeast Connecticut. I am writing you today because I do not support the recent legislation referred to as The Patient Protection and Affordable Care Act of 2010. I urge you and your colleagues in Congress to repeal this law. I believe that our efforts aimed at improving the economy will, in itself, dramatically reduce the disparities in access to health care.

Under the auspices of a progressive government, our country has seen many times of woe. Bigger government and higher rates of spending have driven our economy into the ground. It was only the idea of smaller government and trust in the American entrepreneur that ever caused unemployment rates to drop to less than five percent. More people gainfully employed means more people with access to affordable health care. Is this not our goal? In Europe, economic systems are collapsing. Many of the countries with universal health care have tax rates approaching 70 percent (including ‘value-added tax’). It is commonly held that suppressing the spending power of the citizenry will surely lead to a collapse of the free market, the basis of our economy. I certainly do not want the United States of America to resemble Greece, Portugal, Spain, or Cuba. We are the Great Experiment, and so far, it is working. I fear, though, not for much longer.

I favor universal health care just as I favor universal education and other entitlements but not at the expense of our country. Improvements to the economy will put us in a position to gain strength and enable us to afford such a sweeping paradigm shift in health care. More importantly, a better economy will allow us to do it properly. I urge you to focus on the economy and repeal this dangerous law.

 Sincerely,

Michael F. Schadone

Freedom vs. Health Care Reform

In the United States, we believe in individual rights, some of which are enumerated in the U. S. Constitution. The right to health care is not one of these. As our country prospers or declines, we may amend our Constitution to ensure more rights or take them away. The question, now, is can we afford health care for all? At this moment, I believe we cannot. Other countries have attempted to provide health care for all of its citizens but are facing economic troubles in spite of 70% tax rates (Clark & Dilnot, 2002). I believe that high tax rates are dangerous to the economy because the people and the government compete in mobilizing the economy; whereas with lower tax rates, the small businesses can drive the economy (U.S. Small Business Administration, Office of Advocacy, 2006).

It is my experience that those who overutilize health care are those who are under-insured (e.g. Medicare and Medicaid) and uneducated about the health care system. Further, it seems that the underpayment of costs by the Medicare and Medicaid programs are driving up the recoverable costs to other payors (Brennan & Mello, 2009). This is why I believe that our health care system is as expensive and inefficient as it is. “The U.S. health care system also spends more on administrative or overhead costs related to health care,” says Garber and Skinner (2008, p. 32), but they attribute this to administrative waste where I conclude that the over-administration is needed to meet the demands of an over-regulated and inefficient payment system.

In conclusion, our health care system is linked to our economy, and improving the economy is the only way to ensure that our health care system improves. By adding entitlements, we are forcing the American people to minimize their financial growth and, thereby, their financial freedom to choose affordable health care.

References

Brennan, T. A. & Mello, M. M. (2009). Incremental health care reform. Journal of the American Medical Association, 301(17), 1814-1816. doi:10.1001/jama.2009.610

Clark, T. & Dilnot, A. (2002). Long-term trends in British taxation and spending (IFS Briefing Note No. 25). London, UK: The Institute for Fiscal Studies. Retrieved from http://www.ifs.org.uk/bns/bn25.pdf

Garber, A. M. & Skinner, J. (2008). Is American health care uniquely inefficient? Journal of Economic Perspective, 22(4), 27–50. doi:10.1257/jep.22.4.27.

U.S. Small Business Administration, Office of Advocacy. (2006, September 28). Small business drives the U.S. economy — represent 99.7 percent of all businesses, employ 57.4 million (SBA No. 06-17 ADVO). Retrieved from http://www.sba.gov/advo/press/06-17.html

Pay-for-performance in EMS?

There has been much discussion regarding reimbursement models for health services, and two main themes have emerged, the historical fee-for-service model and a quality-driven pay-for-performance model (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007). While many providers argue that the reimbursement level is currently too low to sustain operations (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007), patient advocates cite an overwhelming number of medical mistakes allowing providers to benefit from poorer outcomes leading to increased needs of critical care services which lengthen hospital stays dramatically (Committee on Quality of Health Care in America & Institute of Medicine Staff, 2001; Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007). While considering more effective designs within our health care system, treatment efficacy, reimbursement paradigms, and patient safety could possibly be used as a foundation upon which to rebuild our health care infrastructure. The Committee on Quality of Health Care in American and the Institute of Medicine Staff (2001) offer “six aims [safe, effective, patient-centered, timely, efficient, and equitable] for improvement that can raise the quality of care to unprecedented levels” (p. 5).

Fee-for-service models, the traditional norm in health care reimbursement, seek to itemize care expenditures based on particular procedures or services rendered to the patient. Though fee-for-service models reward providers for timely, and possibly effective and efficient, delivery of care, it does little to address safe, patient-centered, and equitable considerations.

Financial barriers embodied in current payment methods can create significant obstacles to higher-quality health care. Even among health professionals motivated to provide the best care possible, the structure of payment incentives may not facilitate the actions needed to systematically improve the quality of care, and may even prevent such actions.
(Committee on Quality of Health Care in America et al., 2001, p. 181)

As a paramedic, I am bound to a Medicare reimbursement model that focuses solely on the transportation of the patient and not on the care rendered. For a patient experiencing cardiac chest pain, merely placing them on a continuous ECG monitor and providing transportation to the hospital allows my employer to be paid the same as if I initiated an intravenous line, administered oxygen, aspirin, nitroglycerin, and morphine, and performed serial diagnostic 15-lead ECG readings during the transport. In any case, though, payment is withheld if the patient is not transported. I have to assume that this inequitable reimbursement scheme is replicated across the health care spectrum.

Pay-for-performance models, however, seek to reward the provider for improving the quality of care delivered and “represents an attempt to align incentives in the payment system so that rewards are given to providers who foster the six quality aims set forth in the Quality Chasm report” (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007, p. 36; Committee on Quality of Health Care in America et al., 2001). Some detractors of pay-for-performance worry that providers serving poor and ethnic communities that have typically poor health and preventative compliance will not benefit from such performance measures. The worry is that the numbers of providers will be lacking in these communities, worsening the communities health outcomes (Nafziger, 2010). Though, “pay for performance is not simply a mechanism to reward those who perform well; rather, its purpose is to encourage redesign and transformation of the health care system to ensure high-quality care for all” (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007, p. 44). Pay-for-performance focuses on safety, and a search of the literature does not reveal any complicating risk to patients under a pay-for-performance system so long as the system is patient-centric, taking into account the patient population serviced by each provider.

For instance, regarding a certain type of heart attack called a “STEMI”, or ST-segment elevation myocardial infarction, it is beneficial for the paramedic ambulance to bypass the local community hospital and transport the patient to a primary coronary intervention (PCI) facility for a cardiac catheterization. In this instance, the local community hospital is losing potential revenue. Perhaps if the reimbursement model reflected this evidence-based and patient-centered decision and provided a small monetary reward to the local community hospital for allowing the directed care at the PCI center, then mortality and morbidity from STEMI in the community would be reduced and the local hospital would be rewarded for their involvement in the process even if they did not provide any direct care. This is just one instance in the realm of emergency care where pay-for-performance can help to ensure safe, effective, patient-centered, timely, efficient, and equitable delivery of care to the patient.

As both a health care provider and consumer, I would prefer the pay-for-performance model of reimbursement. As a provider, I am a patient advocate, and as a patient, I will, of course, advocate for myself. Pay-for-performance enables provider growth, evidence-based practice, better patient safety mechanisms, and an overall efficient and a more complete and holistic delivery of care.

References

Committee on Quality of Health Care in America (Author), & Institute of Medicine Staff (Author). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.

Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff (Author). (2007). Rewarding provider performance: Aligning incentives in Medicare. Washington, DC: National Academies Press.

Nafziger, B. (2010, May 6). Pay for performance could hurt docs who serve poor, blacks and hispanics. DOTMed News. Retrieved from http://www.dotmed.com/fr/news/story/12570/

The Socio-economics and Certain Illnesses or Injuries

Kovner and Knickman (2008) describe health disparities as health problems common to specific populations, and they differentiate health care disparities as a “[reflection of] the interaction of health care access and utilization with broader societal issues related to racial and ethnic, socioeconomic, and gender differences” (p. 421). Many social groups take part in risky behaviors. If these social groups are drawn along certain socio-economic lines, then it would appear that there is a causal relationship between socio-economics and certain illnesses or injuries when the correlation is truly the risk-taking behavior. Blacks having a ten-fold incidence of AIDS over whites may be related to preliminary health education with no causal relationship to the access of health care (Kovner et al., 2008). Additionally, Kovner et al. point out a higher incidence of Blacks leaving emergency departments before being cared for. Could this be a result of Blacks seeking emergent care for non-emergent problems? Certainly, there are health problems and health care problems common to specific populations.

Initially, when considering racial and ethnic differences, my views revolve around socioeconomic determinants where causal relationships are not what many would consider. Most, I imagine, would consider the cause of poor care to be uncaring health care professionals, but I would venture that the attitudes of some health professionals are the end-result that correlates to poor care. If a health care provider treats patients who continually dismiss their poor health or take part in risky health behavior without considering the long-term effects, the health care professional becomes dispassionate and disconnected, mistrusting patients, and delivering care that is substandard, but presumed to be aligned with the responsibilities taken by the patients, generally speaking. Ergo, if they don’t care, why should I? This generalization creates a common distrust between patient and provider. Aside from the patient-provider relationship, there seems to be a more daunting issue of access to health insurance, which obviates the correlation to a lack of health care access. What are the causes of these disparities?

How do we address the disparities in health care? First, we need to identify if there are truly disparities, what they are exactly, and what is causing them. Recent research suggests a need to find the methods most appropriate to tackle these questions (Kirby, Taliaferro, & Zuvekas, 2006; Lê Cook, McGuire, Meara, & Zaslavsky, 2009; Lê Cook, McGuire, & Zuvekas, 2009). Do we need to understand the problem? Educating both the providers and patients effectively in how to approach each other as well as instituting quality improvement strategies within each health care practice should assure, at least retrospectively, that all patients within a practice would get the same care as any other patient treated by that practice. Additionally, providing patient education about how to access health care appropriately and effectively would help to avoid some of the pitfalls common in our health care system. Some of which may be attributable causes to many of the health care disparities of today.

In conclusion, I feel that many of the health care disparities are not caused by the health care system, though the relationship is noticeable. There are many other factors that need to be considered, and as Kirby et al. point out, “Researchers and policymakers may need to broaden the scope of factors they consider as barriers to access if the goal of eliminating disparities in health care is to be achieved” (p. I64).

References

Kirby, J. B., Taliaferro, G., & Zuvekas, S. H. (2006) Explaining racial and ethnic disparities in health care. Official Journal of Medical Care, 44(5), I64-I72. doi:10.1097/01.mlr.0000208195.83749.c3

Kovner, A. R., Knickman, J. R., & Jonas, S. (Eds.). (2008). Jonas & Kovner’s health care delivery in the United States (9th ed.). New York, NY: Springer.

Lê Cook, B., McGuire, T. G., Meara, E., & Zaslavsky, A. M. (2009). Adjusting for Health Status in Non-Linear Models of Health Care Disparities [Manuscript]. Health Service Outcomes Research Methodologies, 9(1), 1–21. doi:10.1007/s10742-008-0039-6

Lê Cook, B., McGuire, T. G., & Zuvekas, S. H. (2009). Measuring Trends in Racial/Ethnic Health Care Disparities [Manuscript]. Medical Care Research Review, 66(1), 23-48. doi:10.1177/1077558708323607

Health Care Costs, Quality, and Access

It is the general consensus that the structure and organization of the U.S. health care system is fractured and disorderly. For many health care consumers, especially those who rely on governmental health assistance, there is no motivation to seek appropriate care responsibly. Many of these consumers rely on the local hospital’s emergency department and municipal emergency services for their primary medical needs. The Committee on the Future of Emergency Care in the United States Health System (2006) states “[Emergency Departments] are an impressive public health success story in terms of access to care” (p. xiv), and continues to describe how the emergency departments have “become the ‘safety net of the safety net’, providing primary care services to millions of Americans who are uninsured or otherwise lack access to other community services” (p. xv). With health care comprising one sixth of the nation’s economy, doubling in the last 30 years, the focus should be to create a model of efficient and effective delivery of care so that we, as a nation, may be able to care for our sick and injured without becoming bankrupt (Kovner, Knickman, & Jonas, 2008; Mushkin et al., 1978).

As emergency medical services are considered as the health care gateway for many, allowing the emergency medical services to refer patients into appropriate pathways (e.g. primary care providers, urgent care clinics, psychiatric services) for their conditions would allow for more directed care for the patient with shorter wait times and shorter care times overall. Unfortunately, insurance providers, including Medicare and Medicaid, do not allow remuneration for such services, requiring the transportation component to trigger payment; therefore, the only option left is to transport these patients to the emergency departments. This promotes the inefficient use of such services and continues the current paradigm of inefficiency throughout the system. Though this change would increase insurance payments to emergency medical providers, increasing the initial cost of seeking health care, this would allow the provision of selecting more efficient pathways leading to more cost-effective care. Hopefully, this paradigm would result in an overall net savings.

This is only one example of modifying a current system to be more effective and help to promote efficiency throughout the health care experience. We need to consider where we can shift roles and responsibilities within the health care system in order to promote a more usable system, one that promotes integrity, efficiency, responsibility, and efficacy by both providers and consumers. Once we realize the opportunities that efficient use of current services will offer, we can realign the services to better fulfill the needs of the population where it comes to health and wellness.

References

Committee on the Future of Emergency Care in the United States Health System. (2006). Emergency medical services: At the crossroads. Washington, DC: National Academies Press. Retrieved from http://www.nationalacademies.org/nas/

Kovner, A. R., Knickman, J. R., & Jonas, S. (Eds.). (2008). Jonas & Kovner’s health care delivery in the United States (9th ed.). New York, NY: Springer.

Mushkin, S., Smelker, M., Wyss, D., Vehorn, C. L., Wagner, D. P., Berk, A., … Louria, M. (1978, October). Cost of disease and illness in the United States in the year 2000. Public Health Reports, 93(5), 493–588. Retrieved from http://www.ncbi.nlm.nih.gov/

Reducing our Health Care Expenditures

With the recent signing into law of the Patient Protection and Affordable Care Act (2010), more affectionately known as ‘Obama Care’, much of the health care discussion has turned from deciding what we should do to how we should do it. Many us acknowledge that the current state of our health care needs reformation; the only problem seems to be choosing the best approach. As a licensed out-of-hospital provider, I am in a unique position to observe patients entering our health care system, being treated by our health care system, and exiting (for good or bad) our health care system. I can see that our health care needs are not being met, and I can see both how patients approach their care and how practitioners approach their patients — inefficiently and ineffectively. We need to resolve these issues.

Canada is a fairly close approximation to the United States in locale, geography, economy, and political ideology (Doran, ca. 2000; “GNI per capita”, 2010). It might make sense for us to look towards Canada to see if they have adopted a plan that we could either emulate, or, in the very least, research for a sense of best practices. Kovner, Knickman, and Jonas (2008) describe Canada as having a national health insurance (NHI) system of health care, in that the system is provisioned by a mix of both public and private contributions. Two benefits of Canada’s health care system include a high life expectancy (77.4 for males at birth) and a low cost ($3,165 per capita, or 9.9% of GDP; Kovner et al., 2008, Table 6.2, p. 165). In comparison, Kovner et al. shows that the life expectancy for males in the United States is 74.8 under a system that costs $6,102 per capita (or, 15.3% of GDP). These numbers are significant because we need to understand what we can expect from our investments, and I feel that the average life expectancy is a great benchmark of a health care system as a whole. One worry that I would have, though, is if we were to adopt the same pharmaceutical cost controls, research and development in the industry may suffer, as well as any other technology burdened by cost-cutting measures. I have to assume that the free market would effectively drive these areas, however.

In order to adopt such sweeping changes of our health care system, both liberals and conservatives would have to negotiate their ideals. I am a fairly conservative citizen who believes in smaller government and spending constraints. If reducing our health care expenditures by realigning the modes and methods of health care delivery was realistic, I could be in favor of such a reform. Political agendas aside, Canada’s health care system is certainly one that we should further consider.

References

Doran, H. (ca. 2000). Politics and political parties in Canada. Internet sources for journalists and broadcasters. Retrieved on April 22, 2010, from http://www.synapse.net/radio/can-pol.htm

“GNI per capita, Atlas method (current US$)”. (2010). Data catalog. The World Bank Group. Retrieved on April 22, 2010, from http://data.worldbank.org/indicator/NY.GNP.PCAP.CD

Kovner, A. R., Knickman, J. R., & Jonas, S. (Eds.). (2008). Jonas & Kovner’s health care delivery in the United States (9th ed.). New York, NY: Springer.

Patient Protection and Affordable Care Act of 2010, H.R. 3590, 111th Cong. (2010).