Health care systems and policy

Acute care has been a concern since the beginning of human history since acute care facilities existed, for there has always been a need to treat people as soon as possible after an accident or the onset of an illness. Acute care facilities are those that meet the first needs of a patient before s/he can be transferred to another site for longer-term care. The first facilities that in any way resembled modern acute care (and only barely) were battlefield way-stations where the most traumatic injuries were treated as well as possible.

The first permanent hospital that was designed along modern lines of acute care was probably St. Barththolomew's in London. Opened in 1123, it was designed to provide acute care to those in deadly need. This hospital shifted the care of those in critical need away from the home and to an institution, where the sick or injured would stay until they could be moved back home. The key components were thus the degree of injury or illness, the type of acute-care facility, the type of facility the patient could be transferred to and the way in which the patient could be transferred.

The first hospital in the United States was founded in the 1751 by Benjamin Franklin. Still in use today, the Pennsylvania Hospital was established to provide care for the poor. It provided primarily acute care for people who had been injured. When they were stabilized enough and had a place to go for further treatment they were discharged. In this way -- although the care offered was extremely primitive by today's standards -- the philosophy of acute care was the same. The primary challenges for acute care have always been and remain the severity of the condition of the patient and the fact that such a high level of severity generally means that there is relatively little time for needed treatment. This also accounts for the high cost of acute care.

Acute care expanded its role in terms of overall medical practice in 1954 with the establishment of Medicare, which provided financial coverage for acute care.

Question Two: Chronic Care

Chronic care has a much, much shorter history, at least in terms of formal or professional medical care. Individuals in need of long-term care for illness or injury were cared for at home by family members, friends, and neighbors, or perhaps by paid lay companions. The kinds of conditions that require long-term care -- such as heart disease, kidney disease, diabetes -- have not had good treatments until quite recently. (and, of course, even contemporary treatments are far from adequate in many ways.) as a result, many conditions that can now be managed on a chronic basis historically became acute very quickly and so were not managed as chronic illnesses. For example, until the invention of insulin injections, people diagnosed with Type I diabetes would have lived on average only about a year.

The primary components are the type of disease or injury, the type of facility, the type of lay help provider, and the type of financial arrangement.

With the rise of sophisticated pharmaceuticals and certain medical techniques such as dialysis, formerly acute conditions have been transformed into chronic ones. As this has occurred, there has been a shift in chronic care. While chronic disease was initially treated as uniform -- someone with kidney disease was someone with kidney disease -- chronic disease is now segregated into different stages. Providing treatment keyed to where a patient is on a continuum of a disease or injury (whether the condition is lupus, a stroke, or terminal cancer) ensures that the patient receives the medical care that is most appropriate to the specific stage of his/her illness or injury. At least as important to the development of chronic care is the idea that each stage of a chronic condition requires certain specific psychological and emotional forms of support.

Insurance is often difficult to obtain for chronic care. Chronic care tends to be very expensive because it lasts for so long. Providing affordable, quality care that shifts to reflect shifting patient needs are the primary challenges for chronic care.

Question Three: Long-term Care

Long-term care can be distinguished from chronic care in that the former is generally used to describe care for the elderly or others who are not able to take care of themselves for long periods of time, often for the rest of their lives. Long-term care was traditionally something that took place in the home, with family members taking care of the elderly, those with severe cognitive limitations, those with severe physical limitations, etc. Long-term care is designed for those who are not necessarily sick or injured but who simply cannot take care of themselves on their own.

The key components of long-term care are the type of injury or illness; the type of professional care; the type of lay care; physical, emotional, and psychological care; and financial arrangements.

When long-term care began to move out of the home in the early 1900s -- as industrialization began to shred the traditional family structure -- independent long-term care facilities began to be established under the rubric of "rest homes" or "old-age homes." Often such homes were run by religious or ethnic organizations. In 1935, the Social Security Act allowed for payments to be made to long-term care facilities.

Beginning in 1956. private for-profit institutions became federal for public reimbursement. Public funding became increasingly available for long-term care throughout the second half of the twentieth century. Private insurance often covers some percentage of long-term care, but only a very small percentage. Supplemental insurance can sometimes be purchased to cover long-term care, but this too can be expensive and limited.

The difficulty of paying for long-term care remains one of the most difficult aspects of paying for medical care for many Americans, especially as the population ages. The costs associated with long-term care are high, and this is the primary challenge of long-term care, as is the question of respite care for lay caregivers.

Question Four: Health-Related Behavior

One of the most striking aspects of health-care is that people persistently act in ways that harm their own health. Health-related behavior that is harmful includes smoking; eating a diet high in fats, salt, sugar, and cholesterol; not wearing seat belts; not exercising on a regular basis; having unsafe sex -- and any number of other behaviors that are dangerous depending upon a person's specific condition.

Why people act in ways that are counter to their own health is a complicated puzzle. To some extent, such behaviors can be explained by the fact that people tend to focus on the present and the short-term and ignore the long-term. We are all subject to this behavior and thought patterns. Who has not put off a diet to enjoy a piece of birthday cake? Or decided to sleep in instead of going for a morning walk? The pleasures of the moment can shine so brightly that they blind us to the long-term risks of what we are doing.

Health-care providers must work with patients to help the latter understand the long-term consequences of different kinds of behaviors. However, rather than simply telling patients or clients what to do, health-care providers much create partnerships with their patients. Long-term behavioral change will not come about (except in very rare cases) unless the person involved chooses to make his or her changes. A sense of autonomy is very important to most people, and as a result most patients will resist medical "orders" that they fill strip them of their sense of self. Health-care providers must provide both accurate information and a way for patients to feel a sense of agency.

Health-care providers must also be careful not to be overtly angry at their patients or to blame people for engaging in behaviors that are less than fully healthful. A person may be well aware of how dangerous a behavior like smoking or over-eating is but find it very, very difficult to change his or her behavior. Patient support on the part of health-care givers is much more likely to help people change their behavior and become healthier than will censure or impatience. Making a patient feel ashamed of herself or himself will never be the most effective method of effecting change.

Question Five: Medicare Prescription Act

The federal Medicare Prescription Drug, Improvement, and Modernization Act (also called the Medicare Modernization Act or MMA), enacted in 2003 was the largest overhaul of Medicare in the public health program's 38-year history. The bill was championed -- and signed -- by President George W. Bush. The bill met a great deal of resistance in Congress in no small part because Democratic legislators (along with a few Republicans) argued that the bill would substantially increase the federal deficit, which was already rising to new heights.

The bill did not allow the federal government to negotiate with drug companies to get reduced rates on drugs. Many opponents to the bill in the form in which it was passed argued that the federal government should use its bargaining power as such a mass consumer to bargain for cheaper medications and then could pass these savings on to individuals. This is the strategy used in Canada, where drug costs have been substantially reduced.

The challenges presented by this law have spilled over into the current health-care reform debate. Many people and many legislators who might have been more open to engage in productive dialogue during the current debate were no doubt made more leery of the process and of the possibility that there could be significant reform that would bring benefits to more people while bringing down the federal deficit.

The fears of opponents of the bill were correct in their fears that the bill would been even more expensive than originally budgeted. The initial estimate for the net cost was $400 billion for the period from 2004-2013. However, only a month after the bill's passage, that estimate was raised to $534 billion. It has since been raised to over $550. The cost over-runs in this bill will no doubt continue to grow, even if the health-care reform measures currently being considered are enacted.

Question Six: Single Policy Option

One policy option that may influence the health-care workforce would be a greater empowerment of nurses. Nurses are vital to the welfare of patients and provide the great majority of care. And yet they are often prevented from providing care that they are qualified to give. Allowing nurses to give care that they are now prohibited by law (and custom) from giving would fundamentally change the way that health-care is provided in the United States with a number of different stakeholders benefiting from such a change.

For example, nurses could provide a great deal of the well-baby care that is now conducted by doctors. A child with an ear infection does not in general need to be seen by a physician. A parent with child on her sixth ear infection recognizes the symptoms, which could be confirmed by a nurse on a visit to a home clinic (or via a telemedicine program). If the nurse could then prescribe the appropriate antibiotics, the child would have been treated more cheaply and probably more promptly and with greater compassion. The nurse would also benefit from the increased responsibility and rise in status.