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Public Health and the Healthcare System

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Taleen Bolbolian

on 8 October 2013

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Transcript of Public Health and the Healthcare System

Public Health and the
Presented by:
Shon Augustine, Taleen Bolbolian, Meagan Devine, and Zichen Liu
Chapter 3: Part One
Health System
Chapter 3: Part Two
Case Study: Improved Maternal and Infant Health
Medical and public health strategies contributed to improvements in maternal and infant health
Reducing infant mortality by decreasing amount of low-weight births OR improving chances of survival by medical care
The Burden of Disease and the Changing Task of Medicine
David S. Jones, M.D., Ph.D., Scott H. Podolsky, M.D., and Jeremy A. Greene, M.D., Ph.D. (2012)
Healthcare System
Health strategy
State addressed
Prevention level
Practice domain
Health system: all aspects of the organization, financing, and provision of programs and services for the prevention and treatment of illness and injury

Health Strategy
Health promotion
Specific protection
Early case finding and prompt treatment
Disability limitation
Prevention and Treatment
Health Promotion and
specific Protection
Health promotion activities: modify human behaviors to reduce those known to affect adversely the ability to resist disease or injury-inducing factors, thereby eliminating exposures to harmful factors
Specific protection activities: provide individuals with resistance to factors or modify environments to decrease potentially harmful interactions of health-influencing factors
Early case finding and prompt treatment:
Reduce individual pain and suffering , less costly
screening tests, case-finding efforts, and periodic physical exams
Early Case Finding and Prompt Treatment:Disability Limitation, and Rehabilitation
Disability limitation:
Aim to arrest or eradicate disease or to limit disability and prevent death
Return individuals who have experienced a condition to the maximum level of function consistent with their capacity
Prevention Level
Primary prevention
Prevention of diseases or injury itself, generally through reducing exposure or risk factor levels
Secondary prevention
Identify and control disease processes in their early stage, often before signs and symptoms become apparent
Tertiary prevention
Prevent disability through restoring individuals to their optimal level of functioning after damage is done
Practice Domains
Provided by or under the supervision of a physician or other traditional healthcare provider
Primary medical care
secondary medical care
tertiary medical care
Public health practice
Medical practice
Long-term care practice
Accommodates the activities carried out by any different types of health professionals and workers
Health Services Pyramid
Explanations of each level
Public Health and Medical Practice Interfaces
Medical practice: produce the best possible outcome

Public Health practice: avoid the worst outcome
Health promotion: Community
Specific protection: Community or risk group
Early case finding: Individual and prompt treatment
Disability limitation: Individual
Rehabilitation: Individual and group

Medicine & Public Health Collaborations
We again are seeing collaborative efforts with Public Health Professionals & Practicing Physicians today as we saw in the 20th century when infectious diseases brought the two together
Today in the 21st century, it is modern technology & economics that are now forcing medicine & public health to work more closely together
Collaboration is KEY
American Medical Association & American Public Health Association established an initiative in 1994 to have an open meeting to showcase ideas and collaborate best practice models.
A variety of significant ideas were collected and spread. The monograph,
Medicine &Public Health: The Power of Collaboration
provides many examples of the two working together effectively. This represents the first time the two groups came together in response to mutual interests.
Collaboration between hospitals and Public Health have grown. The community’s are becoming engaged and are learning new ways of providing and promoting health strategies.
Ex: being healthy at work is now rewarding to staff member salaries
The Health System in the U. S
Healthcare is growing more and more & expenses are predicted to grow to $4.5 trillion in 2020. (Fig. 3-5)
By 2020 the health sector will comprise of 1/5 of the nations Gross Domestic Product. (Fig. 3-6)
Compared to any other industrialized nation, the United States is spending way more money than anywhere else.
Unfortunately for us our population is no healthier than nations that spend far less.
Fig. 3-5:National Health Expenditures, U.S (1980-2008)
Fig.3-6: Percent of US National Gross Domestic Expenditures Spent for Health-Related Purposes (1980-2008)
52% of the U.S health costs are going toward hospitals, physicians & clinical services.
10% is being spent on Prescription Drugs.
6% allocated to Nursing Home Care.
Public Health Activity & Program Administration Combined equal 10% ( the same amount spent on prescription drugs.)
Figure 3-7
Figure 3-8
Shows the largest purchaser of health care in U.S. Is still government : private health insurance ,individuals & private funds. The cost is simply something individuals & families are having trouble keeping up with.
Rich vs. Poor:
Aging Population
As population ages the frequent visits to doctors are caused by the amount of chronic diseases they endure that are attributed to aging.
More chronic illnesses = more visits to the doctor.
The treatment costs increase.
Preventative efforts are desperately needed so that the aging population and population at large can eliminate or reduce the need for expensive treatments.
Non-white population is growing 3x faster than white population.
Hispanic population has increased 5x for the entire U.S. population.
Trends show fertility & immigration patterns and heighten the importance of cultural competency for the health professional.
Cultural Competence: a set of behaviors, attitudes, & culture within a system that respects cultural beliefs, background & values & applies them in the services provided.
Family Structure
Demographic Trends:
slowing population growth
Older population on rise
Between 2000 & 2030 people 65> will double
Increased diversity in population
Changes in Family structure
An increasing number of people in the U.S. have no means to pay for healthcare services.
50% chance married couple will reach 25th anniversary (silver)
1 in 3 children live part of life in a 1-parent household.
Women in the workforce more than doubled
Types of service has changed over the years
Family violence, substance abuse,& child welfare services.
Low income families reportedly see physician 50% less than higher income.
Rates are low for prenatal care & child immunizations too.
Women physicians are increasing especially in surgical & medical specialties.
Shortage of R.N. is at crisis level.
Number of hospitals are decreasing.
Admissions, days in hospital & length of stay have decreased.
Employees in hospitals & outpatient visits are increasing.
Managed Care:
a system of administrative controls intended to reduce the cost through managing the way services are used.
By 2000 more than half the U.S. population was served through a managed care system.
Gain vs. Pain
Hospitals will decrease by 50%
Deficit in nurse & dentist professions
Increase in pharmacists & physicians
Public health will be one of the few professions likely to flourish (Hooray!)
Information driven-planning
Focus on community
Broad sense of health services/health in general
In Conclusion
45 million Americans and counting do not have health insurance.
Government wants to reduce cost of health care but it grows harder to provide care for elderly, poor & disadvantaged when new expensive technology plays a role in healthcare.
21st century Healthcare System
More innovative
Greater focus on education, prevention & care management
Moves to improve populations health as a whole
More aware and responsive
Breast-Feeding Services Lag Behind the Law
New York Times
Written by: Catherine Saint Louis
September 30, 2013
This article relates a public health issue of improved maternal and infant care to a medicine and the current state of healthcare
Under Affordable Care Act (ACA) insurance companies are required to pay for breast pumps and lactation counseling for mothers with breast-feeding problems
The aim of this new law is to encourage more mothers to breast-feed
Breast-feeding is correlated with reduced risks of asthma, leukemia and Type 2 diabetes in infants
Breast-feeding Laws
Although insurers have been updating coverage as of January 1, 2013, mothers have found it nearly impossible to get timely help for breast-feeding problems
National Breastfeeding Center assessed breast-feeding policies of insurers nationwide: 28 out of 79 received D’s or F’s
Few insurers have added lactation consultants to their networks, do not specify the kind of breast pump, and/or do not say who qualifies as a “trained provider” of lactation counseling
In one case, did not reimburse the fee for consultation out-of-network
Insurers advise women to get help from in-network ob-gyn or pediatrician (but they do not have adequate training)
Aetna is a notable exception
Mothers are complaining to state insurance commissioners
Time sensitive issue due to insufficient milk or painful infection
Epidemiologic Transitions
-Examination has evolved from just angina, diarrhea, and burns.
-Adding to the roster of epidemiologic transition include gunshot wounds, spina bifida, tetralogy of Fallot, diabetes, hernia, epilepsy, osteomyelitis, syphilis, cancer, croup, asthma, rabies, and urethral stones.

-What was the focus in the 1800s were to spread disease:

a) Apoplexy (causing stroke, seizure, or syncope) was once understood to be expressed from a “nervous sympathy”. (Stomach inducing the head)
b) Doctors believed that a close shave by a cannonball (no close contact) could fragment bones, blind people, or kill them.
c) Physicians were commonly classifying fevers: puerperal, petechial, catarrhal, and spotted fever – however patients did not experience spots on skin nor a fever. ( Unexplainable but only classification to give.
d) Mortality data included consumption, diarrhea, and pneumonia. Society at the time believed teething, worms, and drinking cold water were among many causes of death.
The cause and rate of mortality rate changed in 1900s.
a) Specific microbial causes have been introduced, which led to redefining ongoing infections.
b) These infections included tuberculosis, gonorrhea, and syphilis to be reviewed.
c) Accruing appearances of infections during 1900 time period included diphtheria, measles, pneumonia, scarlet fever, and typhoid.
d) A close view on tropical infections
- worms in immigrants
-outbreaks of plague
- yellow fever
- malaria
Great success in 1912
-Doctors celebrated that society has achieved a great accomplishment of 1911 as being the healthiest year on record.

Turn of the century
- Journal articles celebrate the progress and discoveries made in medicine for the century.
- An editorial (1912c) made a prediction that “Perhaps in 1993, when all the preventable diseases have been eradicated, when the nature and cure of cancer have been discovered, and when eugenics has superseded evolution in the elimination of the unfit, our successors will look back at these pages with an even greater measure of superiority.”
Epilepsy, alcoholism, and feeblemindedness were immensely expressed in society and posed a concern. This led to fears of race suicide and negative eugenics (reduced reproduction of individuals with undesired traits).
Cancer, eclampsia, impotence, heart disease(valvular) became problematic for physicians. These became dominate in causes of death throughout the duration of the 20th century.
Ongoing issues that were brought to medical attention included environmental pollution, climate change, and obesity epidemics. These issues were scattered in civilizations across the world.
With these continuing issues, life expectancy became questionable along with society’s optimistic future for health.
Causes of Death in 1811. Abstract of the Bill of Mortality for the Town of Boston.
Top Ten Causes of Death: 1900 vs. 2010
Definitions and Consequences
How do we define disease?

How do we measure our burden of disease and set health policy priorities?

Merriam-Webster’s Medical Dictionary of Disease- “an impairment of the normal state of the living animal or plant body”

a) What is: Normal? Impaired?

b) What can we call disease?

“ A disease has characteristic signs and symptoms, afflicts particular groups of people, and follows a characteristic course…Disease definitions structure the practice of health care, its reimbursement systems, and our debates about health policies and priorities.” The New England Journal of Medicine, June 2012 (2335)
When Dealing with Disease
Doctor’s role: Names the disease. Works to identify causes, develops prevention process, and how to treat them

Patient’s role: Expresses the intensity of pain and how they believe they got to their current medical state.

After a disease has been identified, determining its frequency, intensity, and relevance is not simple.
Demographers and epidemiologists have complied statistics on causes of death and mortality rates that has been collected for over centuries.

These statistics have been translated into a structure that society can carefully study disease-specific mortality and measures of morbidity.
Accounting for the Burden of Disease
The burden of disease exposes disparities within and among populations.
a) Changes over time in the prevailing diseases
b) The persistence of health inequalities.

Ways in which diseases can emerge
a) New causes
b) New behaviors
c) Consequences of new therapies
d) Changing environmental and social conditions
e) New diagnostic technologies and therapeutic capacity
f) New diagnostic criteria
g) Changing social mores
h) Conscious Advocacy
“Accounting for the history of disease also requires us to examine why some disparities in disease are seen as proof of a natural order while others are considered evidence of injustice.” The New England Journal of Medicine 2012 (2337)

Variations in health and diseases are results from how society structures lives and risks of individuals.
The Roles of Medicine
Best health policy? Does it exist?

Health care and public health programs should unify in addressing the disease burden

As the environment changes, the organism evolves.

Health systems and health policy must adapt as the burden of disease evolves.
Primary Care and Public Health
Exploring Integration to Improve Population Health
Institute of Medicine (2012)
Although public health and medicine have similar goals, historically these disciplines have remained independently operated
New opportunities to combine these sectors are approaching with health care reform and passage of the Affordable Care Act
This executive summary was written by the IOM committee of experts as called together by the CDC and Health Resources and Services Administration (HRSA)
Primary Care and Public Health
Primary care: provides medical services to individuals with immediate health needs
Public health: provides broader array of services across communities/populations to bring health

IOM Committee finds these sectors to be varied and dependent on circumstances therefore a specific model of integration is not possible
Improving population health
Involving the community in assessing needs
Strong leadership to bridge gaps
Collaborative use of data and analysis

Integration can start with any of these principles
Core Principles of Integration
Time for ACTION is NOW!
Growing understanding of the gaps in our healthcare system and need for reform (ACA)
Research continues to show importance of social and environmental determinants of health (a key of public health)
Integration on a Continuum
Committee does NOT advocate for a complete merger
Framework for Action
With IOM recommendations, CDC, HRSA, and HHS need to create an environment of integration
At the agency level, CDC and HRSA need to connect
staff, funding, and data
at regional, state, and local levels
CDC and HRSA also need to create research and learning networks to integrate disciplines, support evaluation of current models, and support development of new models
On Workforce Integration:
Creation of a workforce to support integration
Centers for Medicare and Medicaid Services (CMS) should indentify options for graduate medical education funding
To train providers and to support integrated education programs
HHS Goals
Should improve existing integration programs and develop new initiatives of ACA
Pilot projects
Some health data collected by physicians is already used to improve public health
Do you agree with the IOM continuum of integration?
Rise in costs, passage of ACA
A: Public health interventions are responsible for improvement in health status in the United States since 1900

B: Medical care interventions are responsible for improvement in health status in the United States since 1900
Chapter 3 Debate
Chapter 3 Questions
What can account for as many deaths as car accidents & Breast Cancer combined?
What is the term used to to define an organization unable to reach primary objectives & outcome?
Is an ounce of prevention worth a pound of cure? Yes? Why If not what is the value of prevention in comparison to treatment?
Medical errors.
Outcome Displacement-the original outcome has been shifted by a focus on how well the means to that end are being addressed.
Instead of “Doing the Right Things” for health, “Doing Things Right.”
Best services may not mean adequate services
Discussion of the Burden of Disease
How would you define disease?

What is the top cause of deaths in this century?

What can health care and public health accomplish together?
Discussion about Primary Care and Public Health Integration
Is this the best time of action for integration?
Full transcript