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Running Head: Policy Briefing

Policy Briefing

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HCAD 620 Fall 2016

Tables of Content

Introduction 3

Problem Statement 4

Structure of the Delivery System 5

Managed Care 6

Military 7

Subsystem for Vulnerable Populations 7

Integrated Delivery System (IDS) 9

The Effect of Healthcare Delivery Structure/System 9

The Impact of ACA 10

Alternatives 12

Recommendations 14

References 16

Being a mid-career health policy administrator, the Director of the Louisiana State Health Department has assigned me hired as the Health Policy Coordinator for the Bayou Region of Louisiana.  The institutional healthcare services framework contains one regional medical center, five small community hospitals, a regional health center, and a contracted behavioral health provider group.  In 14 towns, there are physician medical clinics, but most of the Bayou Region is remote, consist of small villages, semi-swamp, or reservation land for several indigenous groups.

According to Federal standards, the BR’s 100% of the population would be assumed rural, and only 23 % live in towns of 20,000 or more.  73% of residents belong to families with at least one member as a full-time worker. In the BR, the occupants who don't live in towns have a tendency to be seasonally employed, in as a part-time employee, or self-employed, with a low probability of employer's offered insurance policy.  Generally, of the uninsured who are poor, (50%) of those are from families with full-time employees. One-fourth of the uninsured are between the ages of 45 and 64, and 26% report being in reasonable or weak health condition. Latest studies of the behavioral healthcare framework, tribal health center, and clinics have identified that the residents of BR are more likely the victims of depression, schizophrenia, post-traumatic stress disorder, and substance abuse.  There is high concern that these problems are linked to increased rates of domestic violence and suicide.

Despite many improvements in the healthcare system over the past decade, the healthcare disparities are still growing that is making a huge part of the BR underserved. The regions that are highly remained underserved are low income areas where the concentration of homeless people is high. Reports by social service agencies have identified that poverty is another fundamental issue for the region. This issue is because the numbers of homeless people in the BR are very high that are mostly living seasonally (or in most cases year-round) in campers, out of automobiles, tents, or moving between campgrounds or camping areas in the state park grounds.  In some cases these homeless people also have families with children.

The healthcare department of BR faces some serious issues in the delivery of healthcare to the underserved groups because due to lack of proper residents and jobs; it is hard to reach these people on a regular basis. Minorities are making a significant part of the underserved group that is more likely at a disadvantage because of language and communication issues. Moreover, poverty and low-income made this population highly resistant to visit medical care centers due to the fear of out of pocket expenses (Mullins, 2005).

The increasing trend of insured health care services has also made it hard for the poor and low-income people to access quality health care services which are another potential barrier. In short, the region is highly exposed to a number of issues such as language barriers, low income, and dependence of allied medical staff (nurses and pharmacists), healthcare insurance trend, and the unique culture and ethnicity, as well as the mindset of the minorities of the region. All these issues are posing serious challenges to the Louisiana State Health Department to overcome the situation and to improve the healthcare service system so that every single individual of the region could become able to access health care services freely and fairly (Mullins, 2005).

The structure of the delivery system in BR is in accordance with that of the overall healthcare structure of the United States. The US has not a universal health care delivery system like many other developed countries. Some various subsystems have been created through market forces and the requirement of some specific population segments. The major subsystems of the US delivery include Managed Care, Military, and Subsystems for Vulnerable Populations, and Integrated delivery systems (Niles, 2014).

• Managed Care

Managed care is one of the major systems of the health care delivery; 1) to achieve efficiency by integrating four functions of the healthcare delivery, i.e. Financing, Risk underwriting, Capitation or discount, and Utilization control, 2) employs techniques to monitor the use of health care systems, and 3) helps in the determination of the of the services on which it should be purchased or in other words, determines that how much amount should be paid to the healthcare providers. This is the most active medical care delivery system in the US in which they major financier is the government. The purpose of this system is to reduce the costs and to improve overall health care system in the US (Niles, 2014).

Under this system, the enrollees (a member that would be covered under a plan), or employees do not purchase an insurance plan from companies directly using traditional means; rather they are directed to purchase from the contractors of the government/chief financier, i.e. from a managed care organization (MCO). Examples of MCO include PPO or HMO. In this situation, MCO deals with other service providers on behalf of the employee or enrollee to get some discounted fees from the service provider (Kamerow, 2008).

A study conducted by America’s Health Insurance Plan in 2009 discovered that people who are opting for out-of-network providers have to pay high fees for getting same coverage. The service providers got paid using different techniques with a guaranteed patient population (Niles, 2014).

• Military

This is a particular kind of health care delivery system that aims to provide health

care services only to the active-duty military officers and personnel of the US armed forces. It is also providing healthcare services to certain non-military services such as National Oceanographic and Atmospheric Association (NOAA), and Public Health service. Under this system, routine ambulatory care, preventive care, and treatment care, mostly provided by salaried health care personnel. Many of them had previously worked in a military force or uniformed services. Veteran administration facilities are used to provide long-term care to retired personnel, while TRICARE program is used to provide healthcare services to the families and dependents of the military personnel (Niles, 2014).

• Subsystem for Vulnerable Populations

To be able to deliver healthcare services to the vulnerable population including poor, uninsured, minority, people living in the geographically or economically disadvantaged regions, and immigrants, the US healthcare delivery system has developed subsystem called a “safety net” of the providers to ensure the delivery of healthcare to those people. The safety net is comprised of the essential health care services providers such as physicians, health centers, hospital’s emergency departments, and outpatient departments, and clinics. These health care providers are specially designed to provide healthcare services to the underserved population. As per the unique role of these centres, some additional features are also added to them for the ease and convenience of the patients such as language translation, outreach, transportation, social support services, nutrition, child care, health education, and case management to fully help the vulnerable population of a state (Niles, 2014).

Government healthcare programs including State Children Health Insurance Program (SCHIP), Medicaid, Bureau of Primary Health Care (BPHC), and Medicare, etc., are few examples of policies and special grants to reach vulnerable populations. Recently, the Affordable Care Act (ACA) is introduced in 2010 to bring a significant change and improvement in the US healthcare system. The ACA refers to two different types of legislations: the Patient Protection and Affordable Care Act (P.L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152). The two legislations together bring an expansion in the coverage of Medicaid to provide intensive healthcare services to the vulnerable population. Moreover, compared to Medicaid, Medicare, and SCHIP programs, the eligibility criteria for ACA is quite simple and effective that encourage the vulnerable population to get access to essential health care services. Although, this system has not reduced the numbers of uninsured as expected by the government, however, it helped the government in getting around 16 million people as newly insured population of the US (Jonas, Goldsteen, Goldsteen, & Jonas, 2013).

• Integrated Delivery System (IDS)

The final major component of the US healthcare delivery system is Integrated Delivery. This system was formed over the last decade through organizational integration. The integrated delivery system constitutes numerous shapes of ownership and strategic connections between hospitals, insurers, and physicians with an objective to provide a range of healthcare services through a network of organizations to provide a continuous healthcare service to a determined population (Jonas, Goldsteen, Goldsteen, & Jonas, 2013).

The current healthcare delivery structure of the US seems less valuable because it is providing high benefits to the wealthy and middle class instead of poor and low-income families. In the United States, regardless of the individual states of the country, healthcare services can be accessed by people in the following ways: health insurance through the employer, registered or enrolled in any of the government healthcare program, ability or financial power to purchase a healthcare policy using private funds, ability to purchase services from private or commercial insurance companies, and ability to access healthcare services offered by government healthcare plans for vulnerable population or charity based services (Jonas, Goldsteen, Goldsteen, & Jonas, 2013).

Health insurance has a high impact on the health care delivery system in the US that ensures a quick and quality access to the healthcare service. Although, the government has offered certain programs to provide health care services to the uninsured, however, accessing those services are subjected to high barriers. For example, federally provided or specified centers or clinics usually have limited facilities and staff and are available only in a particular location with an aim to cover a huge part of a state. The eligibility criteria are very stringent that makes fewer people eligible for the services (Niles, 2014).

Moreover, US laws have empowered the emergency departments of the hospitals to evaluate the condition of patients and provide free treatment only under certain conditions. Otherwise, uninsured people have to pay for getting treatment. The existing healthcare delivery system usually allows the uninsured population to get treatment under government programs only for acute care. In this regard, the structure of the healthcare delivery system actually hinders health delivery to underserved population (Niles, 2014).

Affordable Care Act (ACA) is introduced in 2010 with an aim to bring massive changes in the US healthcare for the uninsured and vulnerable population since the development of Medicaid and Medicare programs introduced in 1965. The new Act has expanded the coverage of healthcare delivery system by improving the quality, efficiency, consumer protection, and by reducing health care costs (Niles, 2014). Although, these reforms have increased the benefits of health care to the vulnerable population and has encouraged them to insure themselves with government programs to get expanded health care services (Monaghan, 2013).

The ACA has great potential to attract and provide healthcare coverage to vulnerable population of the United States; however, still there are some barriers that could create potential difficulties in accessing expanded coverage. The biggest problem is developing awareness among minorities, low-income population, and homeless people about the expansion of the medical care services under government programs because people still are unaware about the expansion of the services under Medicare and Medicaid. The reform has insured more than 16 million people in a short period of 5 years making a number of non-eligible people of Medicare and Medicaid eligible under the new criteria. This reform has effectively brought positive changes in the payment incentives of the healthcare centres, hospitals, and physicians, has reduced the hospital conditions for treating emergency patients, etc. (Monaghan, 2013).

Moreover, the reform has increased the ability of the government to control healthcare system and has encouraged it to make the delivery system more efficient and fair to reach vulnerable population. The current impact of the ACA on healthcare delivery system seems positive and could become more efficient by creating awareness among the underserved population; however, the reform is too new to understand its long-term effects on the health care delivery system (Jonas, Goldsteen, Goldsteen, & Jonas, 2013).

Furthermore, the regulations of the ACA with respect to the individual state laws and the individual small group markets of the private insurance has made the reputation of ACA kind of controversial. The biggest drawback of the ACA is that it has completely excluded the immigrants from the benefits of ACA (Stutz & Baig, 2013). In this regard, the new reform is still making it hard for some of the vulnerable population of the BR region to access healthcare which is hindering the success and poverty controls of the government on the state.

To meet the health delivery challenges in the Bayou Region, Louisiana, the Director of the Louisiana State Health Department needs to develop a proper plan to implement in order to achieve desired improvements in the healthcare system. It is hard to achieve those benefits overnight; therefore, a set of alternatives is presented to the Louisiana State Health Department to achieve desired results.

• The Louisiana State Health Department should launch programs across the state with a focus on the vulnerable population of the region in order to create awareness about the ACA to enroll a high number of people under government-funded healthcare system. It is because the majority of individuals event do not understand what insurance is and when they are called from the Bureau of Primary Healthcare and are asked about their insurance status they usually say that they are insured which is making a huge problem in the region ("Most Americans unaware of impact of ACA on their lives", 2014).

• The Louisiana State Health Department needs to take is to develop critical access hospitals and clinics in order to ensure quick access to the timely and quality healthcare services for the rural population. The development of new hospitals and clinics with more facilities will allow the Louisiana State Health Department to enjoy full benefits of the expansion of the Medicaid. To improve the delivery of healthcare through these hospitals, the Louisiana State Health Department should recognize potential rural health providers and should partnership with those providers to create a network of organizations (Camann & Long, 2014).

• The Louisiana State Health Department should launch a universal healthcare delivery plan throughout the state by eliminating the health care differences of insured, uninsured, and poor population (Soares, 2012).

• The Louisiana State Health Department should redesign the healthcare service providing models to increase their incentives to eliminate fee-for-service models to encourage them to improve the coverage to underserved population to eliminate health disparities (Addicott & Shortell, 2014). For this purpose, the Louisiana State Health Department should consider bundled payments and Accountable Care Organizations as potential alternatives. Both the alternatives are based on certain incentives to the health care providers that they will get in response to the delivery of quality healthcare services to the patients. The development of Accountable Care Organizations is the most appropriate option for the Louisiana State Health Department (Roehr, 2010).

It is recommended to the Louisiana State Health Department to implement the last two alternatives, i.e. the development of a universal healthcare plan for the entire state and the implementation of Accountable Care Organizations Network to improve the quality and accessibility of BR population to health care services. For this purpose, the state government should charge a specific percentage of the income of the working group of the region and needs to pair it with the federal and state healthcare funds to form a single and universal health care system to deliver equal access opportunities to the entire population (Soares, 2012). Using those collective funds, the Louisiana State Health Department should develop Accountable Care Organizations network to help the healthcare service providers in getting certain incentive against the provision of quality health care services.

This would contribute to developing a strong coordination between all the service providers in a region that will eventually improve the overall system of the healthcare delivery. The option will not only help in the improvement of overall health care services but will also assist the government of the state as well as the healthcare providers in making significant savings (Roehr, 2010). Furthermore, this option would better assist the Louisiana State Health Department in developing a universal health care service plan by combining federal government (Medicaid and ACA funds) and state government funds to form a unified health care system to reach out the vulnerable population of the Bayou Region (Addicott & Shortell, 2014).

Addicott, R. & Shortell, S. (2014). How “accountable” are accountable care organizations?. Health Care Management Review, 39(4), 270-278. http://dx.doi.org/10.1097/hmr.0000000000000002

Camann, M. & Long, J. (2014). Health Promotion with Vulnerable Population Groups. OJCCNH.Org,4(1), 29-37. http://dx.doi.org/10.9730/ojccnh.org/v4n1a3

Jonas, S., Goldsteen, R., Goldsteen, K., & Jonas, S. (2013). Jonas' introduction to the U.S. health care system. New York: Springer Pub. Co.

Kamerow, D. (2008). Our perfectly designed US healthcare system. BMJ, 337(nov24 2), a2702-a2702. http://dx.doi.org/10.1136/bmj.a2702

Monaghan, M. (2013). The Affordable Care Act and implications for young adult health. Translational Behavioral Medicine, 4(2), 170-174. http://dx.doi.org/10.1007/s13142-013-0245-9

Most Americans unaware of impact of ACA on their lives. (2014). Pharmacoeconomics & Outcomes News, 714(1), 31-31. http://dx.doi.org/10.1007/s40274-014-1652-y

Mullins, C. (2005). Health disparities: A barrier to high-quality care. American Journal Of Health-System Pharmacy, 62(18), 1873-1882. http://dx.doi.org/10.2146/ajhp050064

Niles, N. (2014). Basics of the U.S. health care system.

Roehr, B. (2010). US health insurer begins shift from fee for service payments. BMJ, 341(oct25 2), c6015-c6015. http://dx.doi.org/10.1136/bmj.c6015

Soares, J. (2012). Social Security: Universal Versus Earnings-dependent Benefits. Economica, n/a-n/a. http://dx.doi.org/10.1111/j.1468-0335.2012.00930.x

Stutz, M. & Baig, A. (2013). International Examples of Undocumented Immigration and the Affordable Care Act. Journal Of Immigrant And Minority Health, 16(4), 765-768. http://dx.doi.org/10.1007/s10903-013-9790-z