Global Health Care Issues and Policies - Term Paper Example

 Global Health Care Issues and Policies Part I: Pivotal event Healthcare is a business. Stand in the hall of any hospital for more than a few minutes and you will know that is true. It, however, was not always that way. It was not always fierce competition for insurance funds and higher pay. There was a time when physicians and nurses cared for patients because they needed care. The shift came over a period of time but has remained with us as a paradigm shift that continue to be part of the system until the system is completely replaced. This paper will discuss that pivotal time in healthcare that we still deal with today. Historically, physicians were not always in competition with one another. Their primary function was care of the patient. Sometimes they did not get paid and sometimes they were paid with things other than money but patients saw physicians in this country. In 1901, however, the American Medical Association under new leadership decided to do away with "ruinous competition"(Light, 2004). In making that decision, they set out to change the face of healthcare, which they did. They restructured the whole of the AMA, placing small groups of influential physicians at the heart of each committee. The first order of business was to reduce the supply of physicians which would in turn increase competition, improving salaries. There was the feeling that the more scientific medicine was, the more a physician should get paid. There was argument that with these moves, patient choice and competition allowing the poor to see physicians would disappear. All of this led to that pivotal moment which this writer believes was the elimination of price competition and free care. This was the third campaign that the AMA set out to accomplish during this change. At this time in history, there were contract physicians and there were actually hospitals that provided care for those that could not afford care. The AMA and the county medical societies decided however, that this was definitely in the way of progress in the campaign. Many contract physicians at the time liked what they were doing and did not want to change. Their peer though, went out of their way to embarrass them and literally pressure them into accepting a different way of doing things. Eventually most of them gave up which set up the hospitals to have to bring other kinds of physicians in, providing competition between physicians and raising prices. This in turn, set up a system in which all hospitals had to become competitive in order to allow them to have the funds to provide care and get physicians in. Today, there are complaints about healthcare and there is an outcry that our system does not work. Physicians make huge salaries and hospitals spend enormous amounts of money keeping up. There are many people in the United States that have an impossible time accessing adequate healthcare. Yes, it is possible to go to the emergency room (which again increases hospital costs) but then follow up is impossible because there are few physicians that will see patients who cannot pay and many will not see Medicaid patients. The end result is sicker and sicker patients admitted to the hospitals with no physician and no prior care and no way to get follow up on discharge. Yes, it is still affecting the healthcare system. In conclusion, the change to no contract physicians and no free hospitals was supposed to improve physician income and quality of care. It definitely improved physician income but IOM studies and the fact that so many receive no healthcare at all speak volumes about quality. There may need to be a second look at the change that occurred when the AMA changed. Part II Cuban Health Care Delivery To better describe the difference in how the Cuban system work, this writer has reviewed the method of treatment for end stage renal disease in both countries. End stage renal disease is a major health problem today, throughout the world, including Cuba and the United States. There is an increasing trend everywhere for the need for dialysis and renal transplant. It is very near epidemic proportions at this time and with the increasing numbers of people with diabetes and hypertension, it is expected to continue to increase. This paper will discuss the presence of end stage renal disease in Cuba and the United States. It will look at the possibility of early intervention in both countries and whether that reduces morbidity and mortality (Almaguer, 2005). In 1996 the Public Health of Cuba noted that this problem was indeed getting much worse. They launched a National program for the prevention of chronic renal failure. This was a program that they expected to have progressive implementation in and have followed that course. The implementation began with an analysis of resources and health throughout the country, then an epidemiological research, continuing education for nephrologists, family doctors, and other healthcare workers and then a reorientation of all of primary healthcare toward the needs of nephrology services and the interventions and surveillances needed (Almaguer, 2005). The main outcomes for this program for Cuba, have been to redistribute nephrology care throughout the country in such a way as to provide earlier intervention for those at risk for end stage renal disease. This brought nephrologists closer to the communities where care was needed. There was also a great improvement in the knowledge of family doctors in renal disease and treatment. This brought the numbers of patients that were registered for chronic renal disease care from 0.59 per 1,000 at the beginning of the transition to 0.92 per 1,000 in 2002 (Zhao, 2008). The healthcare system in Cuba is free access so all of the peoples of Cuba can use this program when needed. Their population is 11,229,688. They have a National Nephrology Net with a National Coordination Center, the Institute of Nephrology. There are 33 nephrology services and 9 renal transplant centers. There are 263 nephrologists. The life expectancy is above 75. There are 67,079 medical doctors which is 1 medical doctor per 167 inhabitants and 31,059 of those are family doctors. 99.2 % of children live to be at least 5 and 95% of all children have had all their vaccines (Almaguer, 2006). Early nephrology care may improve the treatment outcomes and Cuba has managed a system to allow that to happen. Those receiving nephrology care later in their disease have a higher mortality rate according to WHO and supported by studies by Zhao, (2008). Early care controls complications of reduced kidney function. Those that receive late care according to these studies have higher mortality rates. Earlier care means seeing a nephrologist for the first time, 12-14 months prior to dialysis. Only about one third of Americans do this. Patients visiting a nephrologist for the first time less than 4 months before starting dialysis were usually Black, uninsured or had sever comorbid conditions. Access to local physicians was a major issue both because of lack of adequate numbers of nephrologists and because of lack of insurance. In conclusion, Cuba's healthcare system is provided completely by the state and is segregated in such a way as to provide healthcare close to each rural population which provides for healthcare for everyone and more quality in cases of diagnosis like renal failure. Part III Cultural Beliefs The United States is a country of Independence and fierce individualism. There is a need to make one's own decisions and not have someone doing this for them. They are fiercely committed to the capitalistic culture and success is viewed as comfort and financial accomplishment. There is the belief that if you can afford it, you should be allowed to use all the healthcare resources available and sometimes, even if you cannot afford. There is a great dependence on the government for sociological need yet there is a consistent cry for lack of governmental control. Healthcare seen from a very old perspective, is still seen as a right and not a privilege that has to be afforded. This paper will discuss how those cultural beliefs affect healthcare. There has also been, though it is beginning to change, the idea that if one does not take care of themselves, they will still be saved in the end. This relates to obesity, smoking, non-compliance for diabetes and chf and many other things similar to this. There is somewhat of a shift toward better compliance and decreasing these problems, however, in that need to be independent remains the fast food lines. Americans also love their cars which proliferated the marketing of fast food chains and now they drive through everything, banks, fast food, tax companies, you name it. There is little or no exercise needed to do anything at all today. This all affects and shapes the healthcare system. Independence in decision making and the right to have healthcare drives the cost of healthcare up consistently. The patient may insist on a treatment that the physician does not feel is necessary (MRI, IV antibiotics) but because of their insistence, it is done. They also choose the physician and hospital they want to go to which keeps competition going and continues to escalate healthcare costs. With the latest debate on a possible government driven healthcare system, what you hear is not "that is less quality care" but "those people wait forever and they don't get any choices." Again, this is because of that need to be independent in making all decisions. There is a desire to have it paid for by someone else but not to have someone else make the decisions. The United States has also been a melting pot of culture. Those cultures affect how healthcare dollars are spent. Since the advent of the consistent utilization review and the desire to cut costs, there has been an encouragement to not make decisions at the end of like that are meant just to prolong life and not enhance life. Those decisions may not be able to be encouraged in some of the cultural positions that healthcare finds themselves in these days. Patients may hang on for weeks to months on ventilators because the families culture is not to ever stop trying and with technology today, that can be a very long time. The cost is tremendous and many times the hospital is providing the care for free so again, hospital costs go up. In conclusion, Americans are fiercely independent and want to make their own decisions. Those decisions definitely affect healthcare and in most cases it increases the cost of the care. They also have a great dependence on their cars which makes them more unhealthy coupled with non-compliance with physicians orders. There is a desire to have others pay for healthcare but not to make healthcare decisions for them. These are the very complicated issues that will have to change if healthcare is going to change. Part IV: Effectiveness of current Healthcare system For many years, politicians and the people of the United States have said the US healthcare system is the best in the world. It becomes harder and harder to accept this assertion though as we investigate the problems within the system. Those 42.6 million people in the US that are not insured are very aware of the shortcoming of the system and the rising costs of care and the lack of access are approaching a crisis. This paper will discuss the effectiveness of this system. The WHO released a report in 2000 with data about health care systems around the world. In that report, they gave the definition of a good healthcare system. There were three major points and those were good health (making the healthcare status of the entire population as good as possible), responsiveness (responding to people's expectations of respectful treatment), and fairness in financing (ensuring financial protection for everyone). Goodness was defined as the best attainable average level and fairness as the smallest feasible difference . They further said, (WHO, 2000), that a good and fair system had overall good health (low infant mortality rates and high disability adjusted life expectancy), fair distribution of health, a high level of overall responsiveness, a fair distribution of responsiveness across population groups, and a fair distribution of financing healthcare.(WHO, 2000). The United States has the most expensive system in the world based on healthcare expenditures per capita and on percentage of gross domestic product. The United States spends $4,178 per capita on health care which is more than twice the medium of all the other countries and yet the US ranks 37th in overall goodness of the system. The United States is the only country in the developed world except South Africa that does not provide healthcare for all of its citizens (WHO, 2000). Instead there is a confusing hodgepodge of private insurance, Medicare, and Medicaid. Because there really is no system, there are serious gaps in coverage. According to WHO figures 42.6 million people in American are uninsured and many are not able to access healthcare because of it. As for Quality, the United States ranks 26th among all industrialized nations in infant mortality rates. It also ranks 24th among high income countries in disability adjusted life expectancy. Overall quality in the system ranks very low in the world for many things including renal failure and the overall health of the nation. Around healthcare arenas everyday you can hear someone say, "If you do not have insurance in this country, you die." That is what it appears in the statistical data that the WHO presents. In conclusion, the United States has the most expensive, least responsive, hardest to access and poorer quality healthcare systems in the United States. It does not serve its people well. In fact it serves its people 37th in the world. The culture of the people in the United States continue to serve the system the way it is and it seems that no matter what they plan to hold on to the system the way it is but somehow it must change. Part V. Improving Health Outcomes The advanced practice nurse will become more and more important to the system in the near future. The nurse is uniquely connected to the patient which gives her a different perspective than most other healthcare providers. This perspective allows the APN to see the needs of healthcare as a system and allows her to affect policy toward the needs of the populations being cared for. This paper will discuss how the APN can affect health outcomes. Education is key to many things and understanding the big picture of what is helping in the healthcare system is one of those things. Millions across the world are attempting to improve the health of their nations not merely as an academic exercise but as a point of utmost importance. The IOM has worked with many at this stage in studies related to helping the population to be more healthy in an attempt to avoid healthcare and also in providing better quality care when needed. The Robert Wood Johnson Foundation has funded many healthcare studies and grants for education related to moving the nurse "from the bedside to the boardroom". It is one thing for nursing to affect policy inside the institution that she works for and another to affect policy that will become law. If anyone in this country will be able to affect that policy it will be the profession of nursing. The APN is uniquely qualified to do that based on her background, education, and training. APN's learn that collaborative practice and good leadership skills are definitely a necessity in their new endeavors and this is one of the places that those traits are needed. The APN is aware of the clinical and quality needs of the single patient but she is also aware of the overall quality needs of specialty populations. Therefore, in her unusual ability to see these things, she is able to take more to the table than other healthcare providers. She is also prepared through her program of study to be able to enact change. In having that ability, she is able to bring these policies developed in the boardroom atmosphere and make change where it matters. In conclusion, the APN is uniquely ready for the challenge of changing the healthcare system. She is trained and educated in such a way as to allow her to understand and work with the needs of the patient and populations at the source as well as moving that information to the boardroom and public policy arenas. She is then able to bring that public policy back and make change in the arena that the patient is cared for in. Part VI. CAM In 2008 there was the release of a study from the National Center for Complementary and Alternative Medicine and the National Center for Health Statistics on how Americans were using CAM. CAM is a group of different medical and healthcare systems, practices, and products that are not generally considered conventional medicine. Integrative medicine, however, combines the use of traditional medicine and CAM. This paper will describe CAM and how the APN can help put a CAM process in place. The most often used CAM therapies are nonvitamin, nonmineral natural products. Increasing use of things such as deep breathing exercises, meditation, massage therapy, and yoga have taken place. Other often used CAM include acupuncture, ayurveda, biofeedback, chelation therapy, chiropractic, and many others. Many of these therapies would be used by the patient whether or not they are prescribed or provided by their physician or healthcare institution (NCCAM.com). The hospital McDowell Memorial Medical Center has decided that they want to take an integrated approach to CAM from now on or combine CAM with traditional medicine. There is resistance from the physicians and nursing staff because they believe that there is no documented reasons to do this. Like most change this is difficult. Moving from one theory or behavior to another takes balance and long term takes committeemen. Lewin's change theory might be used in this case. Lewin would tell us that the first thing that must happen is to unfreeze this situation. The status quo is always easier than making a change. Education is always a good preparation for change. Using small classes and posters in the elevators giving information about various kinds of CAM will help. Use anything that can be thought of to make the staff think about the CAM process. Many of them are using it themselves and do not have a thorough understanding of what is being ask. The second phase of changing this behavior would be to make movement. The staff must understand that the status quo is not good for everyone. Do patients and staff not have a choice in their healthcare? There are those that prefer CAM to medication. Should we not provide all the alternatives if they are safe? This is where the hospital might bring in some well known speakers about CAM and integration and possibly some CEO's from other hospitals that have made this happen. Along with these upper level managers, bring in physicians and nurses that have been using it and what it means to their patients and themselves. The third phase is to refreeze (Kritsonis, 2005).. At this point, the process replaces the old process. In this case the APN has made the change and is assuring that it stays that way and that the staff do not float back to doing it the old way. This will integrate the new value into the old tradition which is perfect for what is trying to be accomplished in an integration of CAM and traditional medicine. In conclusion, the APN is able to make change because of her abilities and training and Lewins methods of change can help in that process. Change is not easy, especially when affects something that is seen as tradition, which is true in this case. Once the change does occur though it is important to assure that that change remains which happens with Lewins third step. Resources Almaguer, M., Herrera, R., Alfonzo, J., Magrans, C. et. al. (2005). Primary health care strategies for the prevention of end-stage renal disease in Cuba. Renal Failure 32 (6). 374-377. Almaguer, M., Herrera R., Alfonzo, J., Magrons, C., et. al. (2006). Morbidity and mortality in diabetic and hypertensive patients with end-stage renal disease in Cuba. Renal Failure. 28(8). 671-676. Foley, R., Collins, A. (2007). End stage renal disease in the United States. An update from the United States renal data system. American Journal of the American Society of Nephrology. doi 10.1681/ASN.2007/20220. Kritsonis, A. (2005). Comparison of change theories. International Journal of Scholarly Academic Intellectual Diversity. 8(1). Light, D. (2004). A new history of the American Health Care "System" Journal of Health and Social Behavior. 45. 1-24. US Dept of Health and Human Services.(2000). Chronic kidney disease in the United States. Reasons for a National Kidney Disease Education Program. White, S., Chadbab, S., Jan, S., Chapman, J., Cass, A. (2008). How can we achieve global global equity in provision of renal replacement therapy. WHO Zhao, Y., Brooks, J., Flanigan, M., Chrischilles, E. et.al. (2008). Physician access and early nephrology care in elderly patients with end stage renal disease. International Society of Nephrology. http://nccam.nih.gov/news/camstats/2007/camsurvey-fsl.htm http://www.who.com http://www.rwjf.org Read More