Access – What Exactly is the problem?
Are the Problems in The States the same?
Frederick (Rick) A. Curro, DMD, PhD
PEARL Network
New York University
College of Dentistry
May 31st, 2011
Royal College of Surgeons of England
Access to Care
Primary Health Care is essential health care
made accessible at a cost a country and
community can afford, with methods that are
practical, scientifically sound and socially
acceptable.
(Alma Ata Declaration, WHO, Geneva, 1978)
Access to Care
Services are available
Utilization of services – dependent upon financial,
organizational and social or cultural barriers that limit the
utilization of services.
Thus access measured in terms of utilization is
dependent on the affordability, physical accessibility and
acceptability of services and not merely adequacy of
supply.
( The Royal Society of Medicine Press Ltd 2002)
Access to Care
The Health of a Nation
•
Bringing together two opposing forces – individualism and
entitlement - bridged by “humanism”, public health & prevention.
• Health care is conceptually based on ideas from the 1930s –
limited technology, medications and care – palliative care
prevailed.
• A point of differentiation: health care vs. cost of the science
behind the health care.
• Japan vs. an aging society – US Social Security System – Is the
end near?
• As the technology increases the issues of Access to Care get
complicated and costly. Should everyone pay for “technology”?
• Basic medical care PLUS – tiered system ?
Access to Care – Brief History
1870 – First system of socialized medicine based on compulsory
insurance with state subsidy created by Otto con Bismarck after the
Franco-Prussian War.
1920s – Socialized health care implemented by the Soviet Union
1939 – New Zealand first country with a mixed economy to initiate the
direct provision of health care by the state by providing mental health
services free of cost to the recipient following the passing of the Socail
Security Act of 1938.
1940s – After WWII the UK established its NHS, a comprehensive
service which was the basis for most of the European health care
systems.
1960s – the US initiated its Medicaid program to help poor mothers
and their children.
Access to Care
What is the basic issue? – it is not helping your
fellow man in need, that is the humanistic part – it is
supporting your fellow man and family in need
without any incentives to move forward, that is the
Dole Society or Welfare State and dependent upon
the Economic Cycle and growth of a Nation.
What are the limits of taxation on a populace?
Individual responsibility for their own health?
How far should “access go” – immigration issue?
Access to Health Care - A National Paradox
Medicine vs Science – cost??
Humanism vs Individuality!!
You can’t give it away!!
Participation vs Incentive!!
Entitlement vs Dependency!!
Tax Base Shift!!
Model of Society!!
Political Correctness!!
Dole Society!!
Rights of the Populace??
Is Access to Care made complicated to be a barrier?
We Spend More Than One-Half of Our Health
Care Dollars on Hospital and Physician Services
National Health Expenditures, 2008
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.
http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx
The Share of Health Care Paid
Out-of-Pocket Is Falling
The United States Is Not an Outlier with Respect
to How Fast Health Care Costs Are Rising
The Elderly Are a Rising Share
of the U.S. Population
Age Is a Powerful Predictor of
Health Care Use
Large Firms Almost Always Offer Health
Insurance; Smaller Firms Often Do Not
Health Insurance for a Family of Four Cost $9,950 in 2004;
Workers Contributed About 27 Percent of the Total
The Price of a Day in the Hospital Rose
Tenfold over the Past 40 Years
The Number of MRI Machines and
MRI Procedures Has Increased
HMO Premiums Are Rising, but
Profits Are Not
Prescription Drug Expenditures Have
Been Rising at Double-Digit Rates
Prescription Drugs Are a Rising
Share of Health Care Expenditures
The Share Paid Out-of-Pocket for
Prescription Drugs Has Fallen
Private Insurance Is the Predominant
Payer for Prescription Drugs
Access to Care!
A Fundamental Humanistic Question?
Health Care access is a Paradox confronting Nations
worldwide and challenging the very core values of the
populations in culture, humanism, and religion.
Health care with an infinite cost mindset is no longer
viable – the issue of “limits of care”.
No universal definition exists which is consistent with
different government structures, economy and standards
of living, etc.
Access to care varies in the US – x 50 states.
Access to Care
Medical and Dental needs and cost vary according to stage of life – the
value of life?
Neonatal
Infancy
Childhood
Adolescence
Adulthood
Ageing
Geriatric ≥ 75
Elderly
The Disparities of Health Care
Delivery – Insurance Paradox?
Should there be Profits ?
Government vs Private Sector?
Job Creation?
Pharmaceutical Approval Process?
Medical Model of Care
Access to Care
2011 Federal Poverty Level
100% Gross Yearly Income
Family size: 1 $10,890
8 $37,630
Health Centers must use a Sliding Fee Scale Discount – a system to determine
eligibility for patient discounts adjusted on the basis of the patient’s ability to
pay. Full discount with annual incomes at or below 100% of the poverty
guidelines, No discounts if over 200% of the Federal poverty level. Fees
determined by Health Center Board.
Total Quality Management
(TQM)
(Edward Deming)
From a patient’s or provider point of view?
Access to care is proportional to need?
TQM patient care at the lowest cost ?
Six sigma – top down management – much like
health care!
Barriers to Access to Care
Complicated and No Transparency – ever try to figure out a hospital bill?
Language
Culture / End of Life
Financial status / Cost Expectations
Immigration status
Importance of dental care
Fear of the dentist
Available providers
Transportation
Arranging appointments
Insurance coverage
Education
Prevention
What is the health care debt burden on the
populace? (2010)
1. Medical care costs of obesity in US in 2008: $147 billion
2. Tobacco-related monetary costs in US – total annual public and
private health care expenditures caused by smoking: $96 billion
3. Total cost of health care for a family of four in US covered by an
employer-sponsored preferred provider organization (PPO):
$18,074.
4. How much personal responsibility does the populace assume –
cost will determine tolerance.
Access to Care in US
Conclusions
•Very complex issue with multiple subjective variables that affect core values of
a Nation,
• No common definition exists,
• The variables that would improve access to care represent common
denominators across all nations and how they are addressed are dependent
upon the structure of government, culture, sovereignty, and economic system
of the nation,
•There is a humanistic component to the need,
• There is a population tolerance to one individual taking care of another within
the country as well as globally.
•The common framework that bind people together are loosening such as
religion, culture, language making it easier to create barriers.
•E Pluribus Unum
•Ben Franklin, John Adams, Thomas Jefferson
•Continental Congress 1776