Different approaches to health care systems

Health Care

a) the different forms of long-term care for elderly Americans provide choice for patients and their families and so give at least a sense of control to people in a time of need. These people face differing circumstances. Richardson (1995) points out that more than 70% of chronically disabled people receive long-term services in the home from family members and friends, but when circumstances warrant, they can use a formal care system such as home health, mental health programs, social services, nursing homes, rehabilitation facilities, and so on. One problem faced by the system is the difficulty in predicting needed levels and types of long-term care services for the future (Richardson, 1995, p. 195).

Similar issues are raised for the elderly population, noting that this is a population that is increasing rapidly, with greater needs for long-term care: "There are many unknowns in predicting the influences of different life-styles and better medical management of chronic conditions such as arthritis, dementia, heart conditions, osteoporosis, and incontinence..."(Richardson, 1995, p. 196). Different needs require different solutions, so the choices open to the elderly are appropriate.

A b) Still, for many, long-term care is often inaccessible, fragmented, and of questionable quality for many people. This is often a function of funding, or the lack of it, and also of the numbers of people who may need these services. As the number of elderly increases, for instance, so must the number of services available, which may or may not occur and which will have a high price tag for certain. The size of an individual's informal network has an effect on services needed, and this cannot necessarily be predicted. The number of formal care systems depends on need in the past, and if proper attention is not paid to forecasts, these systems will not be ready for an influx to come.

A c) Non-governmental solutions are always possible for some people but not for others. As noted, many people have a network on which they can rely, made up of friends and relatives. Organizations exist to provide some services for patients, including traditional charities and specialized services created to meet a need. Communities support certain charities and may have special facilities supported by public donations or even tax money, and these fill a need as well. Still, there are often too many people in need for such services to serve, and government is often needed to provide services on a more widespread basis. Private services are a necessary adjunct, but government attention still must be given to assuring that the services are sufficient for all those in need.

2. a) the mental health system developed over time from different traditions, different levels of commitment, and for different populations. The system remains incoherent because it has never been fully rationalized, and one of the reasons for this is the ambivalence many people feel toward mental illness and its treatment. The system is also best by problems because of a pluralistic delivery system (Sharfstein, Stoline, & Koran, 1995, p.233).

Different types of mental health personnel serve patients, including psychiatrists, nonpsychoatric physicians, psychologists, social workers, and registered nurses, along with service providers including counselors, occupational therapists, teachers, and other health workers (Sharfstein, Stoline, & Koran, 1995, p. 241). These different types of practitioners use different methods, different theoretical constructs, different drugs, and other different treatments, with no central control to rationalize the system.

To a degree, such differences are simply part of the reality of patient needs, for different problems do require different treatments. However, it is also possible that patients with the same underlying problems may be treated very differently in different places because of the theoretical bent of different doctors and different facilities.

A b) How services are paid for affects how they are delivered and what is delivered, and mental health care is not given the same priority by insurers, businesses, or other payment sources as are physical problems. The inability to pay does not mean there is no treatment, only that it is more likely to come from state facilities. Such facilities have fallen into disfavor, leaving many patients in the community with no care at all (Sharfstein, Stoline, & Koran, 1995, p. 247).

A c) Treatment also occurs in different settings, from psychiatric offices to state hospitals, from private hospitals to specifically metal facilities. The type and efficacy of treatments varies greatly among these different institutions and settings.

A d) as noted, community perception of and relationships among providers of mental health care and community attitudes toward the mentally ill themselves also varies widely across the country. Antagonism toward the mentally ill has increased as more have been turned out of care facilities onto the streets, and a contradiction exists in that encounters with the mentally ill reduce the will to fund services that would take them off the streets and reduce such confrontations. Such attitudes have made the provision of mental health care even more problematic.

3. a) Efforts to make certain that care is appropriate or effective, is a quality concern because quality suggests a beneficial outcome, which will not be reached with inadequate care. Patients want to be certain that they are being given the best care possible, including the latest drugs, the latest treatments, and the best-trained personnel. Patients also want to feel that some oversight authority is making certain that this is the case, because the patient generally does not know what is appropriate or adequate unless told.

A b) Given that patients expect the best car and believe that they are assured of this by any hospital or other medical care facility, inadequate care is always an ethical concern, suggesting that those who are providing these services are not considering the patient first and may be allowing other issues to cloud their judgment. Such inadequate care is also often a legal issue, and this also suggests that lawmakers saw an ethical lapse and sought to correct for it.

Patients are not the only ones who view HMOs as medical facilities without the needed compassion for patients. A survey in 1997 was conducted with 200 primary care physicians in metropolitan New York and found that almost one-half (45%) believe managed care has had a "negative impact" on the quality of physician-patient relationships, while 11% feel that relationship has improved under managed care. Almost half also have considered leaving the profession altogether because of these changes. More than one-half (51%) said managed care has jeopardized their ability to exercise professional judgment, while 47% believe the problem will get worse. Only 10% said managed care has improved their ability to exercise professional judgment:

Why do physicians feel that the quality of their relationship with their patients has deteriorated under managed care? Perhaps the key is how they spend their time. Two-thirds of respondents (67%) said HMOs have caused them to spend more time on paperwork and administration. In addition, 71% expect the burden of paperwork and administration will worsen over the next two years; 46% said they have hired additional non-medical administrative personnel to help them meet managed care requirements (Doctors Say Managed Care Strains Patient Relationships, 1997, p. 24).

Less time spent with patients could also explain at least the perception of less compassion, for doctors may be hurrying through appointments and meetings to satisfy the HMO rather than to offer the best service to the patient.

1997 meta-analysis of the literature indicated that doctors simply do not listen to their patients enough or give them enough information. This study was from Montreal, and based on their Medline search, they reported their findings and made certain recommendations. They cite one study of physician-patient interviews in which patients spoke for an average of only 18 seconds before they were interrupted by the physician. The researchers further claimed that approximately one-third of patients who consult a primary care physician have a psychosocial problem serious enough to impair their functioning or well-being. They further note that these problems are not being detected, perhaps because physicians do not let their patients talk as they should. Still another study is cited, a study that found that physicians underestimated their patients' desire for information in 65% of cases and significantly overestimated the amount of time they spent giving information (Rosenberg, Lussier, and Beaudoin, 1997, pp. 279?83).

What patients want is more choice and greater control, by which they often mean only more information before they give their consent. The managed care model is seen as denying them this. The provision of home care, hospice, and day services may allow for more consumer choice and so satisfy patient needs better. Each type of care offers a different advantage and often for a different population. Hospice care is most often used for the terminally ill and care for these patients at less cost (Richardson, 1995, p. 209). Home care is valuable for those who can afford this choice, which can be more expensive when nurses are required, while the assistance offered by family members can be a boon. Day treatment programs can provide services at less cost because the patient goes home at night after being treated during the day, which often is used for rehabilitating chronically ill patients (Sharfstein, Stoline, & Koran, 1995, p. 249). The mere fact of having more choice benefits some patients by giving them more say in their care.

Patient-focused care involves a method for containing in-patient costs for hospitals and for improving quality by "restructuring services so that more of them take place on nursing units rather than in specialized units in other hospital locations, and by cross-training staff on the nursing units so that they can do several 'jobs' for the same small group of patients rather then one 'job' for a large number of patients" (Kovner, 1995, p. 186). Kovner notes a number of barriers to this type of care. One reason has been that hospitals have not had to control costs to receive adequate reimbursement. However, costs are rising rapidly and creating anger in the public, and hospitals today have to consider ways of reducing costs before legislators step in and force change. Hospitals have an ethical responsibility to think of patients over reimbursement and need to take this into account and make the changes that will reduce costs and serve patients at the same time. Hospital interest groups serve as a barrier because they are made up of doctors and nurses who oppose change and because they do not foster champions who will bring about the changes needed. Again, doctors and nurses have to think of patients and of making the system more responsive rather than of protecting their existing bailiwick from all change. Another barrier is the fact that change often requires physical plant renovations, which might be costly. A careful analysis will show if the benefits would outweigh the costs, in which case this barrier can be overcome as well (Kovner, 1995, pp. 186-187).

Such barriers are not insurmountable, but the will to make changes is required, along with leadership to get things done and to bring a clear idea of what is needed to bear and to get people to support Shane. A lack of leadership is perhaps the greatest barrier to achieving these changes.