Toward a National Health Care Survey A Data System for the 21st Century (1992) / Chapter Skim
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Data Needs for a Changing Health Care Delivery System
Data Needs for a Changing Health Care Delivery System
Pages 19-40
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From page 19... ...
The bedrock issues relate to costs, access, and quality; cutting across them are trends relating to demographics and socioeconomic factors, health and disease, technology, human resources, and related social, legal, and ethical questions. Because space limitations prohibit a historical overview, the focus is on current factors and circumstances; readers interested in details of the evolution of the U.S.
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From page 20... ...
The figures are compelling (Office of National Cost Estimates, 1990; Levit et al., 1991; Aaron, 1991b)
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may, however, partly reflect emerging changes in the health insurance picture: a shift toward health plans with utilization management requirements, more health maintenance organizations (HMOs) and preferred provider organization (PPO)
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From page 22... ...
Many explanations for the upward spiral of expenditures have been advanced. Among them are: the effect of third-party insurance coverage in insulating people from the true costs of care; the ever-increasing, sophistication of medical technologies; the changing demographics of the population; the ability of health care providers to generate demand for their services; lack of certain knowledge about the efficacy, effectiveness, and appropriateness of health care interventions; and rising expectations of patients and others about what health care can (or ought to be able to)
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From page 23... ...
. primary care, including health promotion and preventive and screening services; specialized secondary and tertiary services, including inpatient care of the full range of acute and chronic illness, outpatient and inpatient care for mental and emotional disorders and for alcohol and drug abuse problems; dental care; rehabilitation therapy; and the like; various forms of sociomedical services—home health care, adult day care, and related social services that are aimed at maintaining ill or disabled individuals in their homes and communities and out of institutions; · long-term institution-based care; and .
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From page 24... ...
Complicating the picture of access to health care for the poor is that Medicaid itself devotes increasing fractions of its resources to reimburse elderly people for long-term nursing home care. Of all Medicaid outlays in 1988, for example, 37 percent were for nursing home care, and these accounted for more than 44 percent of all expenditures on such care that year (Office of National Cost Estimates, 1990~.
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Bipartisan Commission on Comprehensive Health Care, 1990~. As a percentage of all people in various income groups, 32 percent of those with annual family incomes between O and 100 percent of poverty were uninsured, compared with 6 percent of those with incomes greater than 300 percent of poverty (U.S.
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. The report characterized problems with quality of care as stemming from three sources: overuse of unnecessary and inappropriate care; underuse of needed and effective care; and poor technical and interpersonal performance on the part of health care providers.
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From page 27... ...
The last-named dimensionvariously termed outcomes, health status, health-related quality of life, patient well-being, and the like has gained considerable attention and utility in recent years (Brook et al., 1976; Gilford, 1988; Ellwood, 1988; Lohr, 1988; Tarlov et al., 1989~. Most experts in this area agree that understanding the relationship between the process of care and outcomes of that care is essential, and they lament the striking lack of information that might demonstrate those linkages.
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From page 28... ...
Adequately addressing this inventory of information in data systems of the future poses an immense challenge to policy makers and researchers alike. HEALTH CARE REFORM The calls for health care reform and the proposals emanating from several blue-ribbon panels in recent years have centered on finding ways to solve particular problems of access to care (especially those of the uninsured and underinsured)
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OTHER FACTORS INFLUENCING HEALTH CARE POLICY AND DATA NEEDS Demographics and Socioeconomic Factors The evolving nature of U.S. society poses notable challenges to health care delivery.
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. Virtually every health status and health utilization measure shows those subgroups as disadvantaged relative to whites; in some cases (e.g., life expectancy and infant mortality for blacks)
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Various types of nontraditional households, such as homosexual couples for whom obtaining conventional health insurance may be a problem, are yet another element of society that poses challenges to health care delivery and policy. (The predicament is exacerbated by the loss of private health insurance among homosexual men with AIDS, although this may be more a consequence of loss of employment owing to sickness than to exclusionary insurance practices per se Kass et al., 19911.
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From page 32... ...
Superimposed on this basic pattern of the incidence and prevalence of acute and chronic conditions is a set of sociomedical conditions that have had or threaten to have great impact on the need for health care. The AIDS epidemic has perhaps been perceived as the most menacing problem in recent years, for several reasons its essentially 100-percent fatality rate, the rapid growth in the numbers and diversity of infected persons, the real and perceived threat to the nation's blood supply, and the biological diversity of the human immunosuppressive virus (HIV)
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From page 33... ...
data as well as outcomes and quality-of-care data, those responsible for amassing that information will need to be increasingly sensitive to these issues. They will also need to design their data collection strategies to take patient preferences and autonomous actions stemming from those preferences adequately into account.
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From page 34... ...
Apart from the many proposals for health care reform that have emerged in 1990-1991, other key steps include the expansion of outcomes and effectiveness research (Brook 5Two recent IOM studies have explored many issues relating to two expensive, life-saving technologies. One concerns end-stage renal disease (IOM, 1991a; Levinsky and Rettig, 1991)
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From page 35... ...
The fact remains, however, that there is a paucity of information on the quantity and distribution of specific technologies according to settings, types of practitioners, and similar variables, as well as on their use according to demographic and health characteristics of patients; no comprehensive national data are collected on technology use. For example, as many types of technologies shift from the hospital sector to the outpatient sector, information from insurance claims is less and less helpful in tracking their use, because of the less comprehensive and less reliable coding of inflation on ambulatory care claims—with the possible exception of coding for visits and procedures, when it is done with CPT-4 (Current Procedural Terminology)
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. Superimposed on these patterns is the growth in the numbers of, or demand for the services of, various types of health professionals, such as dentists, psychologists, speech therapists, physical therapists, nurse practitioners, nurse midwives, and physician assistants.
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the kinds of health care data that actual users of the National Center for Health Statistics provider surveys desired now or might want in the future, (2) their satisfaction (or lack of it)
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. A fourth issue involved specific subpopulations (minorities defined by ethnicity and race as well as groups classified according to age, health status, socioeconomic level, and similar variables)
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; re.;,ulatory systems (state systems for reporting hospital adverse events and incidents; credentialing agencies; the National Practitioner Data Bank for malpractice reporting) ; secondary research databases (the Rand Corporation's Health Insurance Experiment)
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From page 40... ...
That is, the continued uncoordinated development of new, discrete data systems in NCHS and throughout the department with different definitions, documentation, coding protocols, and little ability to be linked for analysis would be a serious mistake. In the panel's judgment, the overriding focus of the integrated National Health Care Survey should be to provide statistics on a continuous basis that reflect the state of health care in the United States with respect to the key dimensions of costs, access, availability, quality, and effectiveness both now and through time.
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