Health Care Issues
Legislation, Trends, Challenges
for Respiratory Therapy Students
Coin of the Realm
• Life--is made up of Words
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Federal Register (20,689 pp as of 4/20/06)
Congressional Record
Presidential Proclamations
Newsletters
Radio & TV Talk Shows
Internet, Blogs
Congressional Hearings
Laws & Regulations
Words Have Power
• Words affect all of us:
– Big Government
– Health Reform
– Patients’ Bill of Rights
– Market Forces
– Ownership Society
– WMD
Law Making In Theory
• Words as Law affect us
• In theory it is a simple process:
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Bill Dropped in Hopper
Referred to Subcommittee/Committee
Hearings
Rules Committee Determinations
Floor
Conference
Floor
Allied Health and Nursing
• Allied Health Funding is through Title VII, a
health improvement act, but limited to
section 755
• Nursing has an entire act unto itself, Title
VIII
Allied Health Funding
• From these major legislative grants (Laws),
Allied Health professions receive:
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Scholarships
Traineeships
Student Loans
Special Project Grants
Formula Grants
Construction Grants
Training Institute Grants
THEN AND NOW
1966
2006
62 Senate Democrats
38 Senate Republicans
295 House Democrats
140 House Republicans
44 Senate Democrats
55 Senate Republicans
202 House Democrats
232 House Republicans
Lyndon B. Johnson
Congressional Seniority
More Receptive Climate
Budget Surplus
George W. Bush
No Seniority
Less Receptive
Budget Deficit
How Do You Get What You Want?
• Persuasion?
• Influence?
• Power?
ALLIED HEALTH LEGISLATION
IMPERATIVES
• Workforce
– Current Personnel Shortages
– Student Enrollment Declines
– Faculty Shortages
• Demography
– Aging of Population
– Fastest Growth in Oldest Cohorts
• Epidemiology
– Chronic Conditions/Disability
What Is Allied Health?
• It’s NOT:
Nursing, Physician Assistants, Public
Health, Chiropractic, Health
Administration, Clinical Psychology, Social
Work, or Counseling
Why Workforce Reform is Critical
• 60-70% of health care is labor costs
• Big part of any employment sector
• It Limits access, spurs cost increases, and
directly affects quality
Broad Trends Affecting the Health
Care Workforce:
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Changing Demographics
Shifting Epidemiology
Economic Disparity and Cost
Technological Innovations
Change from supply to market driven
health system
Demography - Aging
Issues
• Impact on demand for health care
• Rising cost of care
• Adequate workforce
• Intergenerational equity
• Uneven across the nation
Demography - Aging
Size US population by age groups
100
90
80
70
60
50
40
30
20
10
0
12.6
13.4
16.9
22.7
26.7
24.5
39.2
36
34.8
25.4
23.9
23.8
2001
2011
2021
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Triple witching
Aging workforce
Fewer new workers
Care demands and
needs of an aging
population
• …but, the devil in
the details
Demography - Aging
Percentage of Population 65-84 years of age
Percentage
20
17
14
15
9
10
5
10
11
7
4
5
0
1900
1920
1940
1960
1980
2000
2020
2040
Epidemiology
US Life Expectancy at Birth by Gender, 1900-90
Years
90
Women
Men
70
50
48
46
52
48
55
54
62
58
65
61
71
66
73
67
75
67
77
70
79
72
80
74
30
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
Changes in Cause of Death,
1900–1999
Trend: Epidemiology
Issues
• Dominantly chronic
• Expensively acute
• Bipolar patterns of disease and health
• Less and less to do with health care--more with
lifestyle changes
Trend Three:
Economic Disparity
&
Cost
Average Dollars
Average After Tax Income by
income Group
(in 2000 dollars
160000
140000
120000
100000
80000
60000
40000
20000
0
1979
2000
Lowest
Second
Middle
Fourth
Highest
Economic Disparity
Percent of Population at or Below Poverty Rate
20
Percent
16
12
13
14
13.5
13.8
11.3
11.1
11.7
12.1
8
4
0
1973
1980
1985
1990
1995
2000
2001
2002
Economic Disparity
Issues
• Larger and larger number cannot afford
health care
• Incumbents in health care become
wealthier
• Health policy and markets driven to serve
those that have rather than need
• Impact back on patterns of health and
outcomes
Technology
Next generation of technology promises
to reduce cost, move care to
ambulatory settings and improve
outcomes.
– Biomedical
– Information Technology
Technology - IT
The Most Important Step is to
Recognize that Health Care is a
Knowledge Based Service Enterprise
Knowledge Business
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33 Million admissions
4.8 Billion claims
505 Million outpatient visits
1.7 Billion prescriptions filled
 Biomedical
 US investment in
basic and applied
biomedical leads the
world
 Commercial
investment now
surpasses public
investment marking
transition to
application
Percentage of Total
Health R&D
60
50
40
30
1985
Gov't
1990
1999
Private
Growing Private Research
Base
Industry spending R&D to Total NIH budget, 1992-2002
35
32
30
26
24
$ Billion
25
21.1
20
18
17
15
10
13.4
12
9
11
14
12
5
0
1992
1994
1996
1998
2000
2002
Market Driven Health
From Supply Based to Demand
Driven
Cost
DEMAND
Consumer
Satisfaction
Quality
Market Pressures
Health care has been based on the
individual:
Encounters
Financing
Ethics
Relationships
Outcomes
New challenge:
How to balance the tradition of individualism
with the needs of:
Population health
System outcomes
Broader social needs
Desire to balance equity and choice
Consumer
Issues
• Wants choice ….but at what price?
• Increasingly willing to buy value… quality,
access and cost
• Needs are more segmented then care
systems acknowledge…build it and they
will come
• Inevitable exposure to more costs … will
look for help to address
Demography - Diversity
From a majority
culture...
Percentage Ethnicity of US Population, 95, 05, 25
To multicultural.
Percentage
To diversity...
80
70
60
50
40
30
20
10
0
1995
2005
2025
White
Black
Hispanic
Asian/PI
Am Indian
Diverse to Multicultural
Ethnicity of CA Population, 95,05,25
60
1995
2005
2025
Percentage
50
40
30
20
10
0
White
Black
Hispanic
Asian/PI
Am Indian
Continued Disequilibrium in Health
Care
• Costs--Total system costs are a huge
burden
• Variation--Enormous range in definition
of quality
• Over/under supply of care providers,
hospitals, insurers.
• Duplication--Substitutable inputs
• Access--+15% uninsured
How Did This Emerge?
Past
• Constantly expanding health system
• Little accountability - cost or quality
Transition from simple and independent
to complex and highly interdependent
What is driving the issue?
Stressed care delivery system and institutions
– Tighter resources
– Lack of direction
– Greater demands
• Technology
• Quality
– Job cuts
– Uncertainty
– Inability to adapt and change rapidly
• Changing nature of work
– Faster
– Flatter
– Flexible
• Changing demographics
– Race/Ethnicity
– Aging Population
• New values
– Women in labor market
– Gen X workers
New Values
• Next Generation Worker
Want:
• Service oriented
• Anti-institutional
• Not hierarchical
• Flexible, change
welcoming
• Diversity
• Technology
• New skills
• Community of work
Hospital Image
• Staff is on strike, laid-off,
or Angels of Mercy
• Large, cold, unresponsive
institutions
• Work is stressful, highly
structured, and un-fun
• Tied to a professional
career, not open to
change
Problems
• Scope(s) of practice
• Professional Models
– Both unimaginative, traditional, turf building or
turf keeping
Angels of Mercy?
• The historical success of a profession rests
fundamentally on the growth of its particular
source of wealth and status—its authority.
Acknowledged skills and cultural authority are to
the professional classes what land and capital
are to the propertied. They are the means of
securing income and power.
Paul Starr--The Social Transformation of American
Medicine
Hippocratic Oath
• What is the first statement in this oath?
• We think it is, “above all (or first), do no
harm”
• But. . .
I SWEAR by Apollo the physician, and Aesculapius, and
Health, and All-heal, and all the gods and goddesses,
that, according to my ability and judgment, I will keep this
Oath and this stipulation- to reckon him who taught me
this Art equally dear to me as my parents, to share my
substance with him, and relieve his necessities if
required; to look upon his offspring in the same footing
as my own brothers, and to teach them this art, if they
shall wish to learn it, without fee or stipulation; and that
by precept, lecture, and every other mode of instruction,
I will impart a knowledge of the Art to my own sons, and
those of my teachers, and to disciples bound by a
stipulation and oath according to the law of medicine,
but to none others.
Modern Version of the Oath
• I swear to fulfill, to the best of my ability
and judgment, this covenant: I will respect
the hard-won scientific gains of those
physicians in whose steps I walk, and
gladly share such knowledge as is mine
with those who are to follow.
Beware Professional Interests:
• Policy history is guided by the interests of
individual professions
• Population health concerns are secondary
• Partnerships are accepted reluctantly
• Guild mentality pervades everything
• The future of health care should NOT be
determined by internecine struggles
• Most are subject to the same demographic,
social, and economic pressures
Transition Dynamics in Health
Care
Can our professional models survive?
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COST UNAWARE ------------------------- COST ACCOUNTABLE
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TECHNOLOGICALLY DRIVEN ---HUMANELY BALANCED
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INSTITUTION BASED --------------- COMMUNITY FOCUSED
PROFESSIONAL------------------------------------- MANAGERIAL
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INDIVIDUAL ------------------------------------------- POPULATION
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ACUTE --------------------------------------------------------- CHRONIC
TREATMENT ------------------- MANAGEMENT/PREVENTION
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INDIVIDUAL PROVIDER ------------------------------------- TEAM
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COMPETITION ------------------------------------ COOPERATION
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DISAGGREATED--------------------------------------INTEGRATED
We need to re-examine
professional models
– Scopes of Practice
– Specialist – Generalist relationship
– Organization of professional governance
– Financing of care services
– Training and specialization
– New skill acquisition
– Continuing competence
Key Questions:
• What are the broad health workforce
needs to be met?
• What changes must be made to meet
those needs?