Making America’s Health Care As Good As It Should Be

The United States has the distinction of spending more of its wealth on health care than any other nation—at last report, 15 percent of gross national product, compared with 11 percent for Switzerland, the second ranking country, and 9.6 percent for our neighbor Canada. With this level of investment, America should provide all of its residents with quality health care and access to health insurance. Overcoming barriers to achieving that vision and making the nation’s health care as good as it should be is the objective of multiple Institute of Medicine (IOM) studies. These studies include comprehensively assessing the problem of uninsurance and its impact on individual, community, and national health; continuing to articulate next steps in the drive to improve the quality of health care; and calling attention to the importance of health literacy and health workforce diversity as key determinants of the quality and successful outcome of health care.

HEALTH INSURANCE FOR ALL

Insuring America’s Health: Principles and Recommendations (2004) is the culminating and summary report of a series of six studies that collectively comprise the most comprehensive examination to date of the consequences that stem from the widespread lack of health insurance. When the report was issued, more than 43 million U.S. residents under the age of 65 lacked health insurance—roughly one in seven Americans—and the numbers are higher today.

The report makes the compelling case that by 2010, everyone in the United States should have health insurance; calls on the president, Congress, and the nation to act immediately by establishing a firm and explicit plan to meet this goal; and provides a set of five principles that can be used to assess the merits of current proposals to expand health insurance coverage and design future strategies to improve coverage.

The report makes the compelling case that by 2010, everyone in the United States should have health insurance; calls on the president, Congress, and the nation to act immediately by establishing a firm and explicit plan to meet this goal; and provides a set of five principles that can be used to assess the merits of current proposals to expand health insurance coverage and design future strategies to improve coverage. These principles are:



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Informing the Future: Critical Issues in Health, Third Edition Making America’s Health Care As Good As It Should Be The United States has the distinction of spending more of its wealth on health care than any other nation—at last report, 15 percent of gross national product, compared with 11 percent for Switzerland, the second ranking country, and 9.6 percent for our neighbor Canada. With this level of investment, America should provide all of its residents with quality health care and access to health insurance. Overcoming barriers to achieving that vision and making the nation’s health care as good as it should be is the objective of multiple Institute of Medicine (IOM) studies. These studies include comprehensively assessing the problem of uninsurance and its impact on individual, community, and national health; continuing to articulate next steps in the drive to improve the quality of health care; and calling attention to the importance of health literacy and health workforce diversity as key determinants of the quality and successful outcome of health care. HEALTH INSURANCE FOR ALL Insuring America’s Health: Principles and Recommendations (2004) is the culminating and summary report of a series of six studies that collectively comprise the most comprehensive examination to date of the consequences that stem from the widespread lack of health insurance. When the report was issued, more than 43 million U.S. residents under the age of 65 lacked health insurance—roughly one in seven Americans—and the numbers are higher today. The report makes the compelling case that by 2010, everyone in the United States should have health insurance; calls on the president, Congress, and the nation to act immediately by establishing a firm and explicit plan to meet this goal; and provides a set of five principles that can be used to assess the merits of current proposals to expand health insurance coverage and design future strategies to improve coverage. The report makes the compelling case that by 2010, everyone in the United States should have health insurance; calls on the president, Congress, and the nation to act immediately by establishing a firm and explicit plan to meet this goal; and provides a set of five principles that can be used to assess the merits of current proposals to expand health insurance coverage and design future strategies to improve coverage. These principles are:

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Informing the Future: Critical Issues in Health, Third Edition Sources of health insurance coverage and number of uninsured persons for population under age 65 years, 1987-2002. SOURCE: Insuring America’s Health: Principles and Recommendations, p. 79. Health-care coverage should be universal. This is the foundation for all other considerations—everyone living in the United States should be covered. Health-care coverage should be continuous. Continuous coverage, starting from birth, is more likely to lead to improved health outcomes. Conversely, gaps in coverage can interfere with therapeutic relationships and result in diminished health. Health coverage should be affordable to individuals and families. The main reason people give for being uninsured is the high cost of coverage. Lower-income families have little leeway in their budgets for health expenditures, so financial assistance will be necessary for them to obtain coverage. Health insurance should be affordable and sustainable for society. Any major reform proposal will need mechanisms to control spending and encourage use of efficacious and cost-effective services. Everyone should contribute financially through taxes, premiums, and cost sharing—because all members of society will benefit from universal coverage. Reforms should strive for efficiency and simplicity by eliminating complex eligibility rules, underwriting, billing procedures, and regulatory requirements.

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Informing the Future: Critical Issues in Health, Third Edition Health insurance should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable. Basic benefit packages should include preventive and screening services, outpatient prescription drugs, and specialty mental health care, as well as outpatient and hospital services. Variations in patient cost sharing and provider payment levels could be used to encourage appropriate service use. Other important barriers stand between patients and good health care: two that are not widely understood and appreciated are health literacy and the lack of diversity in the health care workforce. HEALTH LITERACY Health literacy is the degree to which individuals have the capacity to obtain, process, and understand the basic information and services they need to make appropriate health decisions. People with limited health literacy experience higher rates of hospitalization and use more emergency services, leading to billions of dollars in avoidable health care costs. It is more than a matter of education: people who have finished high school or college may still not be able to navigate the health system. While reading, writing, and mathematics skills make up part of the basis of health literacy, many other skills and abilities are important, such as speaking, listening, having adequate background information, and being able to advocate for oneself in the health system. Health literacy also goes beyond the individual: it depends on the skills, preferences, and expectations of the providers of health care and health information, including doctors, nurses, administrators, home health workers, the media, and many others. Health Literacy: A Prescription to End Confusion (2004) provides an action plan to help people of all races and ethnic groups, ages, and income levels become better able to manage their health. Efforts will be needed by the public health and health-care systems, the education system, the media, and health-care consumers. In an unusual collaboration, the IOM worked with the Academy for Education Development and the Kellogg Foundation to train young people in Pinellas County, Florida, and Harlem, New York, to map health resources in their communities and help create a wider awareness of health literacy and its impact on the quality and accessibility of health care.

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Informing the Future: Critical Issues in Health, Third Edition DIVERSITY IN THE HEALTH-CARE WORKFORCE Successful interactions between health-care professionals and patients depend on many factors. Important among them is the patient’s sense of comfort with the individual or team providing care. Diversity in the health-care workforce is an important factor in assuring that all patients have confidence in the professionals who provide their care. The United States is now a diverse nation and will become more so as this century progresses. The representation of minorities—African Americans, Hispanics, Islamic cultures—in the health professions is far below their representation in the general population. While reading, writing, and mathematics skills make up part of the basis of health literacy, many other skills and abilities are important, such as speaking, listening, having adequate background information, and being able to advocate for oneself in the health system. Increasing racial and ethnic diversity among health professionals is important because evidence indicates that such diversity is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better educational experiences for health professions students, among many other benefits. In the Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce (2004) describes institutional and policy-level strategies to address this pressing need. Health professions educational institutions should begin by developing and implementing clear mission statements that recognize the value of diversity to their own environments as well as to the larger health-care professions. Admissions should be based on a comprehensive review of each applicant, including an assessment of both qualitative factors that may be relevant to enhancing diversity (race, ethnicity, background, foreign language abilities) and quantitative data that speak to academic skills (e.g., prior grades and test scores). Other recommendations include evaluating federal programs designed to support minority and ethnic students and expanding those programs found to be successful in recruiting and graduating students. Increasing racial and ethnic diversity among health professionals is important because evidence indicates that such diversity is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better educational experiences for health professions students, among many other benefits.

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Informing the Future: Critical Issues in Health, Third Edition U.S. medical school graduates, 2001. SOURCE: In the Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce, p. 44. THE QUALITY IN HEALTH-CARE INITIATIVE The IOM continues its long-standing efforts to consolidate and articulate the knowledge base on which to build a quality health-care delivery system. Crossing the Quality Chasm: A New Health System for the 21st Century (2001) provided a framework and strategy to achieve this goal. Subsequent studies have focused on specific aspects of health-care delivery (such as the issue of workforce diversity) to “drill down” in a particular area and make concrete recommendations for action and research. WORK ENVIRONMENT OF NURSES Nurses are the largest profession in the nation’s health-care workforce. Keeping Patients Safe: Transforming the Work Environment of Nurses (2003) documents the critical role that nurses play in hospitals, nursing homes, and other health-care settings. The report provides comprehensive guidance on how to redesign their jobs and the systems within which they work so that they can provide the highest quality of care. Threats to patient safety occur in four main areas—management practices that lead to failure to follow safety practices, unsafe workforce deployment, unsafe work and workspace design, and institu- Threats to patient safety occur in four main areas—management practices that lead to failure to follow safety practices, unsafe workforce deployment, unsafe work and workspace design, and institutional cultures that discourage attention to safety. Improvements are recommended in all areas.

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Informing the Future: Critical Issues in Health, Third Edition TABLE 1-1 Six Aims for Quality Improvement Aim Definition Safety Avoiding injuries to patients from the care that is intended tohelp them Effectiveness Providing Services based on Scientific knowledge (evidence-based) to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively) Patient-centeredness Providing care that is respectful of and responsive to individual patient perferences, needs, and values and ensuring that patient valuse guide all clinical decisions Timeliness Avoiding Waits and Sometimes harmful delays for both those who receive and those who give care Efficency Avoiding waste, including waste of equipment, supplies, ideas, and energy Equity Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status SOURCE: IOM, 2001 Six Aims for Quality Improvements. SOURCE: Quality Through Collaboration: The Future of Rural Health, p. 24. tional cultures that discourage attention to safety. Improvements are recommended in all areas. RURAL AND SMALL-TOWN AMERICA Rural America is home to 20 percent of the nation’s population, but struggles to maintain physicians, hospitals, and other critical points of access to health-care services. The principles of Crossing the Quality Chasm have been difficult to calibrate to rural needs and resources. Quality Through Collaboration: The Future of Rural Health Care (2004) proposes a comprehensive strategy for meeting the health challenges that rural communities face. Many of the challenges stem from lack of access to core health-care services, such as primary care in the community, hospital and emergency services, long-term care, and mental health. Overcoming these barriers will require an integrated approach to meet personal and popula-

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Informing the Future: Critical Issues in Health, Third Edition BOX 4-1 Core Competencies for Health Professionals Provide patient-centered care Work in interdisciplinary teams Employ evidence-based practice Apply quality improvement Utilize informatics SOURCE: IOM, 2003c. Core Competencies for Health Professionals. SOURCE: Quality Through Collaboration: The Future of Rural Health, p. 81. tion needs at the community level; assist health systems professionals to acquire the knowledge and tools to improve quality; and enhance education and training to increase the supply of health professionals in rural areas. PROTECTING PATIENTS In rural areas and nationwide, the development of improved systems for reporting patient safety data is seen as a critical step in overall quality improvement. Patient Safety: Achieving a New Standard for Care (2004) offers a roadmap for developing and adopting key health-care data standards to support both the exchange of health information that is accessible by all health-care organizations and the reporting and analysis of patient safety data. New information technology systems are needed that operate seamlessly as part of a national network of health information accessible by all health-care organizations. The systems must include electronic records of patients’ care, secure platforms for the exchange of information among providers and patients, and data standards that will make health information easily understandable. Although most of this development must occur in the private sector, government should also provide financial incentives to spur private development of electronic health records (EHR). A related report, Key Capabilities of an Electronic Health Record System (2003), identifies a set of eight core functions that EHR systems should be capable of performing in order to promote greater safety, quality, and efficiency in health-care delivery. Having a common under-

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Informing the Future: Critical Issues in Health, Third Edition Patient Safety: Achieving a New Standard for Care (2004) offers a roadmap for developing and adopting key health-care data standards to support both the exchange of health information that is accessible by all health-care organizations and the reporting and analysis of patient safety data. standing about key functions will improve the capacity of health care organizations to compare the key features of EHR systems, guide vendors in building new systems with enhanced capabilities, help accreditation organizations in certifying systems that are ready for adoption, and guide the federal government as it considers ways to stimulate care providers to invest in electronic health records.