- Payer mix determines the source of payment

- Medicare is dominant payer for the elderly, private insurance is dominant payer for those under 65

- Private insurance pays for 55%

- Public insurance pays for 45%

- 21% of financing comes from out of pocket costs for those under 64 (ie co-pays, deductibles, Rx copays)

In general, increases in expenditures come from three sources:

1. Increase in price of services
2. Increase in utilization of services 
3. Change in mix of services utilized, from less intensive/less costly to more intensive/costly

- Higher price of services

- Greater market power of providers

- More rapid diffusion and utilization of high-technology services (related to distribution of specialists/primary care physicians)

- Administrative costs (all the red tape and difficulty navigating healthcare

- Pros:  Improves health outcomes (sometimes), provides jobs and income, delivers services that people desire, etc.

- Cons – takes away funds from government budget that could be used in other areas (education, infrastructure, etc.), association between high costs and reduced access to healthcare services, and not always associated with better health outcomes

• Experience rating: Focuses on the idea that past behavior determines future behavior. What have we paid in the past for them?
• Community rating : More common if you are a smaller organization. The idea is a few high claims could skew your data, so your data is taken and combined with other small organizations and looked at together (Pooling into larger risk pool)
• Underwriting: Actuaries look at demographics and try to predict health utilization using mathematical models. This is the best choice with no past data is available.
• Medical Underwriting: An individual that needs more services is classified as high risk. A physical or questionnaire can help insurance company better assess individuals health and make a predication about their perceived risk.
• Adverse Selection:idea that people who are sick enroll in health insurance and the healthy people don’t. This creates a narrow pool of risks. Insurance companies are always trying to guard against adverse selection.

• Moral Hazard: The idea that if you have coverage you are more inclined to seek health services and more willing to take risks. If you don’t have coverage you are less inclined to seek health services and less willing to take risks.
• Coinsurance max: cap on total of how much you as patient will pay out of pocket
• Deductible: amount you pay out of your pocket before your insurance begins picking up any of the costs of healthcare
• 3 tier Rx Coverage: Generic drug, preferred drug, not-preferred drug
• Co-payment: flat dollar amount you pay upfront when seeking health services
• Coinsurance: a percentage amount you pay when seeking health services
• Premium: the amount you pay just to have insurance coverage
• Out of pocket costs: co-payments, deductibles, coinsurance

• Providers: You can't choose whatever provider you want.  You can only see providers within the plan's network unless there is an emergency.
• Self referral to a specialist is not allowed for most plans, you have to go through a primary care doctor first, and he/she has to refer you.

• Copays - you know what you will pay.  In contrast, other plans have coinsurance, which is a % of the cost so you don't know what you will have to pay.
• No deductibles

• Only office visits have co-pays, outpatient and inpatient care requires deductibles and coinsurance

• Providers: you can go to whatever provider you want, but will have to pay higher out of pocket expense for providers outside of the plan's network.
• Self referral to a specialist is allowed, but usually MH/CD (Mental Health/Chemical Dependency) is an exception

• Funding - the individual, employer, or both fund the account.  It is most common for both the individual (the employee) and the employer to fund the account
• Rollover - account balances remaining at end of plan year will rollover to next year.
• Plan requirements - yes, the individual must be enrolled in a qualified high-deductible health plan (IRS determines deductible and out-of-pocket maximum)
• This account is tax-exempt, so IRS places limit on amount of money in it

• Funding - the employer funds the account
• Rollover - maybe, employer makes the decision whether or not the account balance will rollover to next plan year.
• Plan requirements - no

o   Insurance company assumes risk

o   Utilized by small employers

o   Employer assumes risk

o   Utilized by large employers (Typically over 5,000 workers)

§  Large enough pool to reduce volatility

o   Benefits

1.     Control over plan- can design plan to fit within budget, one that is attractive to members of company.

2.     Ease of Administration- Governed by ERISA Federal Regulations- but don’t have to comply with state regulations

3.     Save money- employer now holds risk and there is a reduction in the charge from the insurance company for taking on the risk.

o   If a bad year occurs with a lot of volatility, insurance will cover

1. ERISA
2. COBRA
3. HIPAA

• fee-for-service: payment system in which physicians and other providers bill for each unit of service they provide
• capitation: payment system used in managed care in which provider is paid a fixed predetermined amount on a regular basis (usually monthly) for the provision of all covered benefits to the insured individual, risk if use more than projected level, can be adjusted for age and sex
• pay for performance: proposed  method based on the extent to which providers meet predetermined outcomes for patients, focuses on outcomes rather than process of care
• reimbursement by episode of illness: reimbursement based on the entire episode of care rather than on a series of specific procedures and services
• per diem payments to hospitals: per day billing including hospital’s operational and capital costs
• global budget reimbursement: method in which the full amount of of financing for a particular budget cycle is prospectively determined, must manage this amount to cover all expected costs for the budget period (used by hospitals in Canada)

• tech/drugs, 
• supplies/salaries, 
• liability/insurance
• Prevalence of chronic disease
• Aging Population
• Consumer choices and neglect/ignorance

•  
  • Characteristics of managed care; minimal out-of-pocket costs, provider networks and restrained access to specialty care, financial risk sharing.

• People were concerned about rising health care costs. People understood that Fee-For-Service practice led to overuse of procedures.
  • FFS focused on individual, acute care that was largely patient initiated, this created incentives for overservice.
  • No  need for referral, people can seek and physicians could provide essentially unlimited healh services.
  •  Focus shifts from episodic care of the individual patient to holistic care of individuals and groups of individuals.

• Intended to avoid over or underuse of care and provide a greater accountability at all levels

• Ultimately aimed to contain and/or reduce healthcare expenditures.

• Example: Kaiser- own their own hospital, have own physician staff.

• Core concept is to increase consumer awareness about health care costs and provide incentives for consumers to consider costs when making health care decisions
  • Lower future increases in premiums
  • Higher deductibles
  • Lower premiums mean lower short-term costs for employers
  • Potential high out-of-pocket spending for consumers

•  
  • Departure from previous health care financing principles
  • Consumers have greater responsibility for cost containment
  • Emphasize individual responsibility and ownership
  • High deductible Health Plans
    • Consumer responsible for costs up to specified deductible level- can pay out of pocket or with funds from savings account
    • Plan begins to pay for services after consumer has reached deductible
    • Many plans require cost sharing after deductible is met, up to out-of-pocket max
    • Plans may pay for "Preventive" benefits (ex: mammograms) before deductible is met

•  
  •  
    • Employers and individuals can contribute to the account (tax preferred for individuals)
    • Unspent funds can be rolled over for future health care needs
    • Provides consumers with incentives to spend account wisely

• Only employers can contribute to HRAs (no limit to contribution), money contributed can only be used for medical expenses.
• Controlled by employers
• Plan typically does not follow employees once they leave the job.

• Can be established by a group or individual, or through employment. Individuals, employers, or other can make contributions to an HSA
• HSA belongs to the individual and is still available if employee leaves a job, but terms of contribution may be limited.
• Like an IRA for qualified medical expenses. In order to make contributions, you must enroll in an IRS-qualified high-deductible health plan (which have lower premiums).

•  
  • Part A = Hospital Insurance and covers inpatient hospital care, limited skilled nursing facility care, home health and hospice care

•  
  • Part B = Supplementary medicare insurance, which covers the services of physicians and outpatient clinics (this is an optional component which beneficiaries may choose to purchase for a monthly premium-- the premium amount is variable between individuals and  linked to reported amount of individual income)

•  
  • Part C = Medicare Advantage Program, and is based on plan-specific cost sharing.  was established in 1997 to attract more Medicare beneficiaries into managed care plans

•  
  • Part D = Outpatient prescription drug coverage; was established in 2003 and coverage became effective January 1, 2006

•  
  •  
    • Note: Medigap is covered in the book, but these are individual supplemental private health insurance policies (but the content of these policies is regulated by the government).  These plans help to cover the considerable out-of-pocket price-sharing expenditures associated with Medicare

•  
  • Known as a vendor payment program
  • Payer of health services for more than 13% of the U.S. population at any given time
  • Eligibility is inconstant/episodic because improvement in an individual’s financial circumstance may terminate coverage
  • Medicaid usually does not have premiums & few programs have implemented deductibles; limited cost-sharing
  • See page 143 for a list of covered services

• Federal public health insurance programs were introduce in the 1960s (Medicare in particular) and altered the balance between private and public health insurance in the U.S. health care system.  The public insurance that existed before came primarily from the state level (and was known as workmen’s compensation).

• 2010: 47 million people
• 12% of federal budget, over 1/5 of national health expenditures
•  Although covers mostly over 65, 16% are under 65 and permanently disabled
•  ½ of beneficiaries have 3 or more chronic conditions. ¼ have cognitive impairments
•  Many have supplemental insurance coverage to fill gaps (34% have employer-sponsored, 22% Medicare Advantage)

• All 65+ who are citizens or permanent legal residents
• Those under 65 after receive Social Security Disability Income payments for 24 months
• Those when end-stage renal disease and Lou Gehrig’s disease

• Part A: Hospital Insurance Trust Fund (taxes)
• Part B: Supplementary Medical Insurance Trust Fund - general revenues, beneficiary premiums, beneficiary cost sharing
• Part C: NOT separately financed b/c provides benefits under A,B, D
• Part D: general revenues, beneficiary premiums, state payments

• Health care reform law changes: reduced spending of $428 billion from 2010-2020
• Financing challenges: rising health care costs, aging of US population, declining ratio of workers to beneficiaries, negative economic factors·

• Due to Medicare’s strategies for cost- containment, hospitals and providers restoring to more cost-shifting (cross-subsidization)

• Currently, pregnant women & children under 6 with family income under 133% FPL. Kids 6-18 under 100% FPL. Elderly and disabled receiving supplemental security income
• State have discretion to expand Medicaid eligibility
• With health care reform, all those under 65 and at or below 133% of poverty level

• Health and long term care services (including dental, translation, vision)
• Federal & state jointly decide what services are covered (federal outlines minimum, states have authority to define these aspects)
• States have choice to cover “optional services” so Medicaid benefits can vary widely across states

• Federal-state partnership. Federal funds 57% of all Medicaid (however, during recession 66%)
• Federal Medical Assistance Percentage FMAP (varies based on state per capita income relative to national average)
• To receive federal matching, state programs must cover “mandatory services” as specified in federal laws

Beneficiaries pay minimal to no out of pocket costs (copays, coinsurance, deductibles)

• Concerns: Rising expenditures, “churning,” access to providers willing to accept Medicaid
• Health care reform law changes: eligibility based solely on income so if under 65 and below 133% FPL (funded by federal gov’t), eligible. Standardization in eligibility across states. Simplified enrollment.

• Offer coverage to employees and their families
• Educate employees about their health plan (not about health)
• Very limited role in delivery of health services
• Occupational health, flu shots, screenings, health fairs
• Strategic focus
• Retaining employees and attracting new employees by having the most attractive health plans compared to other companies. The did this by:
  • Offering competitive benefits
  • Focusing on employee satisfaction rather than health outcomes
  • Managing costs

• Recognition that health of employees has larger business implications and can affect worker productivity
• Employers are beginning to embrace a larger role in health and health care and want to be far more involved in the health and productivity of their workforces
• Strategic focus
• Cost containment strategies
  • To save money on health care spending and maximize their investments in health care for their workers, employers are getting more involved by pressing for better cost containment strategies. Because without cost reductions, health care costs will overwhelm all payers’ ability to provide coverage; health coverage will become less affordable; working families will continue to struggle; and, with the exception of the health care sector, U.S. job growth could slow or cease.
• Long-term solutions to improving health and productivity
  • Many employers are migrating toward the "superhighway" with a focus on long-term solutions aimed at improving the health and productivity of their workforces. However, some have started focusing on short-term fixes aimed at reducing medical cost alone - with some having plans to move away from directly sponsoring health care benefits.
• More involved in health of employees
  • Employers point toward a trend where employers are requiring more of employees and their health

• Employer Sponsored health insurance began as a perk to attract good employees. Today, it has become expected. Over 63% of Americans under the age of 65 are insured by employer-sponsored health plans.
• Most employers offer their employees some form of managed care health insurance. This is the insurance format that we are all familiar with. We have doctors and hospitals that are “in network” and “out of network.”
• Because healthcare costs a TON, employers try to focus very heavily on reducing costs. Until recently, there was little to no health education by the employer. Sometimes an employer would have a health fair or something along those lines. Now, there is recognition that healthy and happy employees are most productive and benefit the business in the long run. Also, employers are seeing that preventative care can be a way of reducing their healthcare expenditures.
• For LARGE employers, it is more cost-effective to self-insure their employees and develop specific plans tailored to their needs.

• By 1980, health spending was second-fastest growing component of the federal budget (after interest payments on national debt)
• Medicaid support often largest or second-largest part of state budgets (often larger than education)
• Governments lose billions of dollars in tax revenue each year because employer health premiums are not taxed and health-related expenses are tax-deductible – the deductible for employer-sponsored health insurance is the most expensive tax break in the system

• From 1980 to 1990, the cost of employer-sponsored health services increased threefold and consumed 3.9% GDP
• Health services by businesses in 1990 was higher than after taxes profits
• Increasing health services affect businesses’ abilities to fund retiree health programs that current and former employees believed were a benefit of their employees
• Number of firms providing health benefits to people who retire before they reach the age of Medicare eligibility continues to decline
• Business strategies for containing health services expenditures: refusing to offer insurance, self-insuring, exemption from state-mandated benefits, increasing employees’ share of co-insurance, high-deductible plans with health savings to encourage employees to become more aware of health service expenditures

• Fear of losing all assets to catastrophic medical event = worth of employer-sponsored insurance
• Share of costs increasing, lifetime coverage of expenditures limited or capped, benefits reduced for employees and dependents as employers address cost of providing health insurance, salaries and wages might decrease

• Change in Mix of Services
• Figure out what works best and for who
  • Center use of technology
  • Comparative Effective Research: today you have one way of treating patients, then a new more expensive method arises for a rare disease but can be used for more prevalent diseases as well but does the cost actually outweigh the result (is it actually better than the old method?)
    • a lot of research is done to see if it works but not if it’s actually better
• How do we control pricing
  • try out different models to pay and reimburse different providers, trial and error
    • Pay for performance is currently being tried in certain hospitals to look at quality
  • Look for ways to reduce spending specifically with medicare/medicaid
  • Manage administrative expenses
    • the new health reform will set limits to reduce these expenses
• Looking at Utilization of Services
  • Disease management
    • look at the population <-managing conditions has a lot to do with home life as well (Wellness programs are attempting to help!)
  • Avoid unnecessary readmission, quality improvement
    • Centers of Excellence <- creat incentive to go to these centers
  • Focus on Prevention

• Dr. Markowitz stressed the role of generic manufacturers and how they influences pricing in the pharmaceutical industry.
  • i.e. their ability to produce the same drug without the lengthy R&D process and multiple approvals enables generic drugs to be sold at drastically reduced prices, causing significant losses for the larger companies that developed the drugs first.
• Repeatedly mentioned how much conflict is occurring within the industry at the present time.
  • Companies accused of withholding information, suppressing safety data, and cutting corners during testing to get drugs to the market faster.  
    • Vioxx debate: companies allowing politics to influence their processes. Dr. Markowitz referenced this drug several times in his presentation.
• Emphasis on the influence of regulation on industry. Significant slowdown in new drugs being introduced. 60% decrease between late 1940s and 1961. New regulations enacted in 1962.
• Diseases like HIV and cardiovascular diseases are much more manageable with pharmaceuticals.
• Who pays for clinical research?
  • Federal Government
    • National Institutes of Health
    • Various funds given to universities.
  • Private Funders
    • by far, private funds are the most significant and provide the most for research
• FDA does not test drugs, but regulates (oversees) the production of drugs.
  • Current commissioner is Margaret Hamburg
• essential, but also very difficult, to balance economic, political, and technological influences when dealing with pharmaceuticals.

1. Physicians
   1. These are the first point of contact in the traditional health services system for most users
   2. Physician practice settings: 22% hospital based, 78% office based
   3. Generally perceived as the leader/ director of health services, entry for hospital admission, and the controller of access to prescription drugs, medical equipment, and other services
2. Public Health Workers
   1. In 2004, 552,061 worked in federal, state, and local public health agencies
   2. Some provide direct service to clients (i.e. a public health nurse), some are involved in maintaining a safe environment or administrating a broad range of PH programs, including those related to bio terrorism
3. Physician Assistants
   1. Emerged as a profession at the close of the Vietnam War, when members of the medical corps sought a way to use their training in the peacetime economy.  Duke University is credited with est. the first PA training program in the early 1960s
   2. PAs are medical professionals. They typically obtain medical histories, perform examinations and procedures, order treatments, diagnose illnesses, prescribe medication, order and interpret diagnostic tests, refer patients to specialists as required, and first-assist in surgery. Physician assistants' scope of practice is spelled out in their PA-Physician practice agreement, and they can not practice in a manner other than prescribed by their supervising physician. PAs are employed in primary care or in specialties in urban or rural regions, as well as in academic administration. PAs may practice in any medical or surgical specialty, and have the ability to move within and between different medical and surgical fields during their careers.
4. Advanced Practice Nurses
   1. Two types: nurse midwives and nurse practitioners
   2. Nurse midwives provide prenatal care, labor, and delivery services, and postpartum care for mother and infant.
   3. Nurse practitioners were developed not only to address the perceived shortages  of primary care physicians but also in recognition that nurses could function clinically well above their customary levels.
   4. NPs are registered nurses who receive advanced training that emphasizes the nursing model of care
5. Nurses
   1. The largest group of health services providers.  
   2. 2008: there were more than 2.9 million licensed nurses (though not all active in workforce)
   3. They have a degree of professional independence, but they usually function as members of a team under the direction of a physician or an Advanced practice nurse
   4. Two thirds are hospital employees, but the market for outpatient settings is growing rapidly (i.e. home health care, school based health, and workplace health centers)
6. Pharmacists
   1. The AMA est the Council on Pharmacy and Chemistry in 1905 to set standards for drugs and drug evaluation, and physicians began controlling the access of drugs to patients through prescibing.
7. Dentist
   1. Emerged a profession once technology allowed for the retention of diseased teeth, the prevention of dental decay, and the ability to correct dental malformations.  
   2. Dentistry has never had a dependant relationship with medicine, and dentists do not function under the authority of a physician
   3. 63.1% work solo, 20% with one other dentist, and 16.9% with two or more

• Rising number of physician’s assistants
  • More affordable for patients --> higher demand
  • Cap on physician residency openings --> PAs can fill in the demand gap of the primary care workforce
• The supply of adult primary care physicians is declining rapidly
  • Specialized careers can be more lucrative --> can earn more money to pay back student loans
  • Cap on residency openings
  • Only 1/3 of physicians in primary care
  • Only 7% of 4th year medical school graduates planned careers in primary care
• The health care workforce is aging
  • Nursing
    • Popular in the 50s/60s, not as popular in the 70s-90s
    • by 2010, half of RNs are expected to be over age 50
• Concentration in cities/urban/more affluent areas
• Gender/race disparities between providers and patients
  • The Hispanic and black populations are most underrepresented according to their percentages of the US population
  • The number of minorities living in the US is increasing but the number being admitted to medical school/graduating is staying relatively constant
  • Young physicians: more females (<45 years old); Older physicians: more males (>45 years old)
  • Majority of physicians are white (74%) or Asian (13%)
• 65M people live in “Health Professional Shortage Areas”
  • It is difficult to increase the physician supply chain in a short amount of time
• Concern about the extent of federal financial support for GME (graduate medical education)
• IMGs (international medical graduates)
  • Level of training must be examined
  • May cause a “brain drain” in the country they are from
  • May take doctors out of countries that really need them
  • IMGs may want to work in the US because they can earn more money
  • May be willing to work in underserved areas of the US
• Nursing
  • Lack of faculty willing to work in nursing schools
  • Shortage of slots in nursing schools and a shift in more 4-year programs --> shortage

• Predicting a HUGE shortage of physicians in the future
  • difficulty estimating demand for physician services (here are the different ways):
    • needs-based approach
      • Estimate the overall health needs of people across the country
      • Based on how many people have certain conditions, this is what we think demand for services will be
      • Problems:
        • Not everyone utilizes services according to their needs (over/underusage)
    • demand/utilization-based approach
      • Looks at historical demand data and project that forward
      • Problems:
        • Changes in the way we practice medicine
        • over/underutilization just gets pushed forward rather than fixed
    • benchmarking approach
      • Comparing what occurs in the U.S. to what occurs in other countries
      • Problems:
        • Populations vary from place to place
        • Health systems vary from place to place
    • look at the # of insured
• Where are physicians practicing?
• are they practicing full time?
• are they providing patient care services?
• what types of services are they providing (ie - generalists vs. specialists; types of specialists)?
• are there substitutes that should be considered (ie - PAs, nurse practitioners)?
• is the workforce diverse and acceptable to the population (ie - race/ethnicity, language, etc.)?
• Supply of Primary Care physicians
  • population is growing/aging --> increased demand for PC services
  • improved health insurance coverage --> increase demand for PC services
  • ⅓ physicians in the U.S. in primary care...why?
    • debt
    • prestige
    • work-life balance is challenging (you’re always on call)
    • monotonous work
• Geographic distribution of physicians
  • 65M people live in “Health Professional Shortage Areas” (not enough MDs for a given # of people in the area)
    • where is the incentive to send someone to the middle of nowhere?
    • National Health Service Corps --> sends people there for a fixed time through $$$ incentives
• Gender/Racial/Age makeup -- see Katey’s section above
• Other issues:
  • more specialists means more expensive care that offers minimal improvements to health
  • tough to increase physician supply in a small time span
  • federal financing for GME (residency)
  • international medical graduates

• #s - need more
• Age - ½ of all RNs are over 50
• shortage of slots in nursing schools
  • nursing leaders pushing to move to almost completely baccalaureate-level education/training programs
• increasingly demanding and intense workload --> some functions might not need nurse-specific skills and training (wasted efforts)
• states are changing practice laws to allow Nurse Practitioners more autonomy and broader scope of practice

• more Rx’s being dispensed --> need more pharmacists
  • expaned clinical role (patient counseling; chronic disease mgmt; mgmt of complex drug therapies) --> more pharmacists
• are we using pharmacists to their full potential?  (Ph.D to count pills?) --> extensive training could be better used elsewhere
• Innovation in communication, information, and technology could decrease demand

-Focus diseases: PTSD, MST, Depression

-Focus diseases: PTSD, MST, Depression

-PTSD- substance abuse and adverse medical conditions

-Depression- Pregnancy complications and suicide

-MST- Anxiety around males

-Damaged relationships- lack of social support

-Reduced productivity in society- interruption of daily functioning

-Increasing national costs- disability payments

-Homelessness- 1 out of every 10 homeless  veteran under the age of 45 is a woman

-non-compliance with privacy and safety policies

-complex eligibility process and long waiting periods

-incomplete information on available resources and services on VA website

-Absence of clear guidelines for experience and training necessary for work with victims of sexual trauma

-Fear of harassment from male providers

-Perceived lack of available services

-Social stigma

-Secondary reason- funding and the global budget (restricts allocations of funds to providing mental health services)

-Women’s Stress Disorder Treatment Teams (WSDTT)

-One-on-one and group treatments

-Women’s Trauma Recovery Program (WTRP)

-Offers psychological treatment and social adjustment programs

-Specialized inpatient and residential care facilities

-Separate wing for female veterans ensures comfort

-Assigns female providers

-Grace After Fire

-Directly engages female veterans in health care decisions

-Enables personal control over health with direct access to resources

-Taking Charge

-Instills greater self-efficacy and self-confidence to overcome stigma of PTSD and related conditions

-Teaches reactions to the threat of physical and sexual violence

• Lack of housing and long-term employment for adults with autism
• 1 in every 110 children are diagnosed with autism
• Cost of caring for all people with autism in US is $35 billion per year

• Legal Guardianship process
  • Takes court case and all involved complications (cost, time, etc.) to allow the adult with autism to stay legally dependent once they turn 18
• Program Absorption
  • Adults with autism are can be unfitting absorbed into programs because of lack of any other options. Program may not adequately address there needs

•  
  • Long Term

• Financial and Emotional strain
• Development of anxiety and depression disorders

•  
  •  
    • What are the primary reason this healthcare need is unmet?
    • Financial barriers

• Very high costs and a lack of sufficient financial resources
  • Cost to society per individual is $3.2 million per lifetime
  • This societal cost is mostly due (1) to the current high costs of adult care, considered direct costs, and (2) to the lost productivity resulting from coping with autism, considered indirect costs
• The government does fund high quality housing programs, but the programs still fail to meet the high demands from the autism community because they lack sufficient financial resources

• Lack of public pressure and understanding of Autism Spectrum Disorder
  • Consequently, there is a severe lack of public pressure for governments to take action and provide assistance for adults with ASD.
  • Without public pressure, there is no incentive for the drafting of new comprehensive policies and legislation.

•  
  • Sociopolitical barriers

• Lack of policy and programs addressing adults with autism
  • No policies address ASD specifically
    • Instead, many adults with ASD receive government support only because they fit other criteria such as low income.
• Existing policies focus on the needs of children, little attention giving at adulthood
  • For instance, Medicaid housing benefits for autistic individuals stop after age 21 in most states.  However, the federal government has recently issued Medicaid waivers for nine states (Arkansas, Indiana, Kansas, Louisiana, Pennsylvania, Wisconsin, New York, New Jersey, Virginia) that extend these services beyond the age limit
• Programs fail to serve for the long term
  • The Vocational Rehabilitation Act of 1973, for example, aims to provide access for individuals with disabilities to any program, service or activity receiving federal funds. Funds are made available to provide provisional job training and employment-development assistance at the state level

•  
  •  
    • What strategies/programs have been developed and implemented to address this need?

• TEEACH Model
  • TEACCH is a program for individuals with autism under the UNC School of Medicine and has a supported employment program that boasts an incredible retention rate of 89%
  • This employment program utilizes the unique strengths and interests of each individual, identifies appropriate jobs, and provides extensive long-term support.
  • TEACCH excels in providing individualized support in the long term in order to fully address the housing and employment needs of adults with ASD.
• Farmstead Model
  • The Farmstead programs are aimed at meeting the needs of adults with autism by providing necessary housing and sense of purpose through a farm environment
  • Here, residents are able to learn vocational skills related to farm living, giving them a direction and purpose to their daily routines.  They live with other adults with ASD and are able to receive care as needed from the available staff.
  • One relatively controversial aspect of this model is that the design inherently isolates those individuals with autism away from the center of society, placing them in a secluded society of their own

•  
  • What can we learn from these strategies/programs?

• Successful strategies and programs are
  • Long-term
  • Provide individual support

• Lack of mental health services for Native American victims of sexual violence.  The target population is Native American women living on reservations.
• 1 in 3 Native American women will be a victim of sexual assault in their lifetime.
• 34% of women in this population have been raped in their lifetime.
• Native American women are more than 2 times more likely to be raped or sexually assaulted than women in the US in general.

• Individual mental health consequences such as depression, PTSD and substance abuse.

• The long-term consequences occur when Native American women do not receive adequate treatment for their mental health disorders.
• Individual: Diminished interest in daily activities, significant weight loss or weight gain, Insomnia or increased desire to sleep, fatigue and loss of energy and long-lasting feelings of worthlessness.
• Family: These are the consequences resulting from short-term and individual long- term effects.
  • Lack of cohesion in the family:  Substance abuse and suicidal tendencies that follow incidences of sexual violence can tear the family apart.
  • Family relations: Women who experience acts of sexual violence lose enjoyment and satisfaction with their daily lives which can cause them to draw away from their families.
  • Intimate partner relations: After acts of sexual violence, women experience fear, sexual dysfunction and decreased sexual interest which can lead to problems problems with significant others.
  • Financial Implications: When women suffer from mental health disorders it is hard for them to keep a job.  This lowers the family income, putting financial strain on the family.

• Community: The Native American community is very connected, so any individual or family consequences are also felt by the community.  On top of the emotional consequences, the community feels the financial costs as well.
  • The 2009 economic victim-related costs of IPV in the US are estimated at 67 billion.
  • There is also a degradation of cultural identity and women’s roles in the community.

•  
  • What are the primary reasons this health care need is unmet
  • Lack of mental health services

• Geographic barriers: Mental health services are limited in rural, isolated areas, such as reservations.  Also, Native American women on reservations may not have the access to transportation to get the services in other communities.
• Lack of Funding: The IHS really only allots funding for the physical consequences of sexual victimization such as STDs and pregnancy.  Also, the mental health services that are funded are mostly western style psychotherapy treatments.

• Cultural Barriers: Native Americans highly revere the elderly population, but most of the doctors on reservations are younger because they are offered a reduced course load as long as they offer to work on a reservation for a certain amount of time.  Native Americans also prefer ethnically matched physicians who are aware of and sensitive to their cultural beliefs and values.
• Language Barriers: Approximately 280,000 Native Americans speak a language other than English in their home.  Because of this, it is hard for them to communicate with their doctor what they are seeking treatment for, especially if the illness is an emotional pain rather than a physical pain.

• Women tend to feel shame and embarrassment after an act of sexual violence.
• Victims also face the risk of being blamed for their own victimization.
• Because of these feelings, female victims of sexual violence tend to internalize their emotional pain rather than seeking treatment.

• The IHS offers these services for free, but they are ineffective and culturally inadequate.
• Consists of one-on-one physician and client therapy sessions.
• Native American recognize the need for professional help, but only in the informal, community setting in which they are comfortable.
• Even if Native American women try these western psychotherapy services, they usually choose to quit treatment because they feel it is ineffective.

• Native Healers: Incorporate spirituality and cultural traditions into their therapies, but they can be extremely expensive.  Average cost per visit, $388.
• Community-based Ceremonies: Are effective because they invite community members to participate in the therapies.  It incorporates culture and spirituality into the healing process.
  • Sweat-lodges
  • Healing Circles

• Puyallup Tribal Health Authority: Short-term crisis oriented counseling and ongoing individual mental health counseling are available.  However, these mental health services are not specifically geared towards victims of sexual violence.
• Crownpoint IHS in Crownpoint, New Mexico: This facility offers one psychiatrist, 2 therapists, and 1 traditional counselor.  However, this service is also not geared towards women victims of sexual violence.
• Pit River Health Service in Burney, California: Individual and group counseling is provided by a licensed clinical social worker.  A licensed clinical psychologist is also available for mental health testing.  However, these services are western psychotherapy based and are not adequate enough to serve a large population of Native women.

• Direct cost: patient care, prevention programs in schools, workplace
• Indirect costs: higher absenteeism, restricted activity, decreased work skills

• Unmet Need:  When patients move between care settings, gaps in care create dangers that can lead to adverse effects and readmission.  Our unmet healthcare need focuses on the transition between hospital and home.  These deficiencies largely stem from three parts of the discharge process – internal hospital strategies, patient and caregiver education within the hospital, and different types of follow-up measures
• Who is affected:  Any patient who undergoes a transition between hospital and home has the potential to experience the negative outcomes caused by an initial fragmented discharge process.  

• Short-Term:  negative health outcomes for the patient and emergency readmissions, which are often not mutually exclusive
• Long-Term:  unnecessary and avoidable expenditures not only for the healthcare sector, but for the patient as well.  Also, it creates a negative feedback loop that inadequate transition causes for healthcare providers, in that patients are cyclically in and out of a system that does little in assessing and changing the quality of the discharge process.
• Important to address this need:  growing pressure to control healthcare costs and improve quality of care. As well, the current fragmentation apparent in discharge pathways raises significant questions as to where the boundaries should be for providing care.

• Lack of accountability among healthcare providers
  • Who follows up:  hospital physician, PCP, outpatient center, etc?
• Lack of incentive and motivation to better manage the discharge process
  • For example, many hospitals are based on the fee-for-service method in which doctors are paid depending on the number of procedures they provide.  This focus on quantity of care rather than quality is one of the major reasons this healthcare need remains unmet.  

• Internal Hospital Strategies:
  • Electronic Medical Records (EMRs) to streamline patient information to keep doctors, physician assistants, nurses, and case managers on the same page.   
  • Digital prescriptions are sent directly from a physician assistant to a pharmacy, which substantially improves efficiency and safety.
  • Discharge and Admission Specliasts:  delegation of both admission and discharge procedures to physician assistants and nurse practitioners.   
• Patient Education Strategies:
  • Print Materials:  describe recovery steps, dieting and lifestyle recommendations, medications, when to get help, and other important information.
  • Interactive Software:  both educational and support systems to educate patients from their computer.
  • Professional Instruction:  hospitals rely on physician assistants and nurses to educate and interview patients before discharge.  During the education process, health professionals demonstrate useful procedures like self-injecting with a syringe
• Patient Follow-Up Strategies
  • Effective communication between hospitals and primary care providers (PCPs)
    • EMRs and delegation of discharge specialists help PCPs get on same page in order to follow-up
  • Home care providers
    • Sent by both hospital and/or insurance companies
  • Monitoring patients through emerging healthcare IT systems
    • Technical support systems that transmit data from a patient’s home to a physician’s office.  

• Effective communication between hospitals, primary care providers, and patients is crucial to minimizing readmissions
• The most effective strategy for patient education is a combination of hands-on learning from healthcare professionals, traditional print materials, and interactive software programs.
• Following up with patients is of utmost importance to reinforce patient education and decrease readmission rates.
• Multi-lateral and multi-level approach is key to improve quality of care and keep costs down.

•  
  • Unmet need is access to HIV and STI (sexually transmitted infections) testing for homeless youth. (youth ages 15-24)
  • 1.6 million homeless youth in the US are affected, as well as society as a whole due to how easy it is to spread STI.

•  
  • short term consequences
    • deterioration of health
    • poor quality of life
  • Long term consequences
    • increased prevalence of STI
    • spread of STI to homeless as well as non homeless individuals

•  
  • Individual level barriers
    • cultural barrier between homeless youth and the health care provider
    • the homeless youth’s priorities are on food and shelter
    • some have mental disabilities and substance abuse problems
  • interpersonal level barriers
    • Discomfort with healthcare setting where testing is available
    • unsure about right to consent to care
    • Many are victims of survival sex and abuse
    • worried about confidentiality
  • Community Level barriers
    • location of clinics that offer testing is often unknown
    • some african americans feel that there is racism towards them
    • some projects simply run out of funding and cant afford to provide testing
    • there is no publicity for programs that are in place so they often go unexplored

•  
  • Strategies to adress the need
    • make it more accessible/available, as well as acceptable by getting rid of stigma
    • offer same sex consulting to increase comfort factor
    • use Lay health advisors and approach teens in the streets
    • use mobile clinics to make the testing more accessible to the youth
  • what can we learn
    • the importance of catering your interventions to your target audience
    • the importance of accessibility and comfort in such situations
    • the need for funding for projects like this to succeed.

• Affected: First responders (firefighters, police, and EMTs) in North Carolina
• Unmet health care need: Lack of access, awareness, and education about CISM (Critical Incident Stress Management) in North Carolina
  • Lack of standardization of CISM across NC counties

•  
  • What is CISM?

• Debriefing process used by first responders to mitigate the effects of short-term and long-term stresses
  • Debriefing - structured group meetings or discussions about a traumatic event
  • Short term stresses: car crashes, fires, disasters
  • Long term Stresses:
    • Emotional - being away from family, not feeling like they’re making a difference
    • Physiological - disruptive sleep schedule, need to be on high alert for long periods of time
• Follows Mitchell Model
  • uses peer debriefers from EMS services

•  
  • What are the short and long-term consequences of this unmet need? Why is it important to address this need?

• Short Term: Mental Health Issues: PTSD, physical ailments, sleep disorders, difficulties with relationships, increased substance abuse
• Long Term: Chronic mental health issues, burn out, switching occupations
• Importance: Cost to EMS departments for retraining, sick days, health and well-being of EMS personnel

• Funding
  • Peer counselors must pay for own trainings and travel
    • May also have to take vacation days
• Perceived Need
  • EMS professionals may see emotions as a sign of weakness
• Education and Awareness
  • All counties should have access to CISM, however, results from the survey showed that some disaster management personnel in NC are not aware of the service

• VA CISM
  • CISM is a part of the Department of Health and there is a paid position for a CISM coordinator who coordinates the regional teams
• NC Program - lack of a coherent structure

• Lack of Intervention programs for Pregnant Alcohol-Abusing American Indian Women. These pregnant women are defined to be age 18-44.

• Maternal Health: Impaired physical coordination and memory, blurred vision, slurred speech, slowed reaction times, blackouts, anterograde amnesia, vomiting
• Child Health: Pre-term birth (a baby being born before 37 weeks of pregnancy), which includes inhibited development that result in underdeveloped organs and organ systems.  
• Financial: Pre-term birth costs include costs pertaining to maternal delivery, medical care, and various services within the first year of birth.

• Maternal Health: Acid peptic disease, severe brain damage, mental deterioration, liver disease, cardiovascular diseases, depression, suicide

• Child Health:
  • Pre-Term Birth: high mortality risk, health and developmental problems including acute respiratory, gastrointestinal, immunologic, central nervous system, motor, cognitive, visual, auditory, behavioral, social-emotional
  • FASDs which include FAS
    • FAS characterized by facial abnormalities, small head, poor coordination, growth deficiencies, mental disabilities, and/or impaired social functioning
• Financial (Individual): Diversion of funds from “essentials” that include food, bills, pre-/post-natal care, and healthcare. Inability to meet financial obligations could result in homelessness.
• Financial (Societal): Utilization of public-sector services such as health insurance, special education, and other social support systems.

• Lack of trained trusted professionals: Few Native medical school graduates. High physician turnover. These factors limit the development of strong patient-physician relationships.
• Lack of routine screening: The lack of routine alcohol use screening, intervention programs, and counseling or guidance services for pregnant American Indians permits pregnant alcohol abuse to continue and preventable birth complications to develop.
• Financial barriers: High out of pocket costs. Low-to-no coverage.

• Warped perception of alcohol threat: Warped perception of alcohol abuse. Desensitization to consequences. American Indian women perceive minimal threat levels from alcohol use that also vary with type. However, modern medical science links any alcohol use during pregnancy to birth complications.
• Low perceived cessation benefit: Benefit of resources and services low. High financial cost outweigh benefit.
• Provider mistrust/cultural barriers: Weak patient/provider relationships because of contrasting cultural beliefs. Traditional Indian vs. Modern Western Medicine. “Outsider” physician recommendations that conflict with traditional Indian remedies and renewal ceremonies are often dismissed.

• Reformative nativism: American Indian reform movement that emphasizes the revival of traditional practices and limiting Euro-American influence (including alcohol use) on their peoples as a healing mechanism.
• Sweat lodges: A traditional pre-rehabilitation ritual during which an enclosed area is filled with steam to “purify” the women of toxins (alcohol, drugs, even negativity). This psychologically and physically renewing technique is often used to mentally prepare women to accept other standard treatment programs.

• Psycho-educational Programs: self-esteem classes, anger management, parent education.
• Substance Abuse Treatment: 12-step program (like AA), alcohol education, a spirituality program, and a specialized medicine wheel class.
• Social Services: Assists with financial issues, life management skills, and legal issues if relevant.
• Services to Family Members: Family therapy services as needed. Weekend client interaction with loved ones encouraged to facilitate reentry into the family