Question

Health care is highly regulated in many countries. Access to care remains a debate whether it is a right or a privilege. Discuss public health and regulatory systems in the United States and the Sub-Saharan country you chose for prompt 1. How is the healthcare system coordinated? What is the role of public health? How is healthcare regulated?

Answer 1

HEALTH

Health is a dynamic state of complete physical, mental, spiritual, and social well-being and not merely the absence of disease or infirmity.

PUBLIC HEALTH

Public health is “What we as a society do collectively to assure the conditions in which people can be healthy

HEALTH CARE SYSTEM COORDINATION

Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care." For some purposes, they noted that other definitions may be more appropriate.

COORDINATION IN DIFFERENT PERSPECTIVE

Patient/Family Perspective. Care coordination is any activity that helps ensure that the patient's needs and preferences for health services and information sharing across people, functions, and sites are met over time.⁴

Patients, their families, and other informal caregivers experience failures in coordination particularly at points of transition. Transitions may occur between health care entities (see definition under "additional terms") and over time and are characterized by shifts in responsibility and information flow. Patients perceive failures in terms of unreasonable levels of effort required on the part of themselves or their informal caregivers in order to meet care needs during transitions among health care entities.

Health Care Professional(s) Perspective. Care coordination is a patient- and family-centered, team-based activity designed to assess and meet the needs of patients, while helping them navigate effectively and efficiently through the health care system. Clinical coordination involves determining where to send the patient next (e.g., sequencing among specialists), what information about the patient is necessary to transfer among health care entities, and how accountability and responsibility is managed among all health care professionals (doctors, nurses, social workers, care managers, supporting staff, etc.). Care coordination addresses potential gaps in meeting patients' interrelated medical, social, developmental, behavioral, educational, informal support system, and financial needs in order to achieve optimal health, wellness, or end-of-life outcomes, according to patient preferences.⁵

Health care professionals notice failures in coordination particularly when the patient is directed to the "wrong" place in the health care system or has a poor health outcome as a result of poor handoffs or inadequate information exchanges. They also perceive failures in terms of unreasonable levels of effort required on their part in order to accomplish necessary levels of coordination during transitions among health care entities.

System Representative(s) Perspective. Care coordination is the responsibility of any system of care (e.g., "accountable care organization [ACO]") to deliberately integrate personnel, information, and other resources needed to carry out all required patient care activities between and among care participants (including the patient and informal caregivers). The goal of care coordination is to facilitate the appropriate and efficient delivery of health care services both within and across systems.

Failures in coordination that affect the financial performance of the system will likely motivate corrective interventions. System representatives will also perceive a failure in coordination when a patient experiences a clinically significant mishap that results from fragmentation of care.⁶

Additional Terms. Definitions for additional terms relating to care coordination are presented below.

Health care entities. Health care entities are discrete units of the health care system that play distinct roles in delivery of care. The context and perspective will determine who precisely those units are. For example:

• From a patient and family perspective, entities are likely to be individual health care providers with whom the patient and family interact, such as nurses, physicians, and support staff.
• From a health care professional perspective, entities may be individual members of a work group, such as nurses, physicians, and support staff in a particular clinic. Or they may be provider groups, such as a primary care practice, specialty practice, or urgent care clinic.
• From a system representative(s) perspective, entities will likely be groups of providers acting together as a unit, such as medical units in a hospital, hospitals as a whole, specialty clinics within an integrated system, or different clinical settings within the health care system overall (i.e., ambulatory care, inpatient care, emergency care).

ROLE OF PUBLIC HEALTH

Prevents epidemics and the spread of disease

 Protects against environmental hazards

 Prevents injuries

 Promotes and encourages healthy behaviors

 Responds to disasters and assists communities in recovery

 Assures the quality and accessibility of health service

Public health is a basic component of health care systems. However, to many people the definition and role of public health are not clear.

The definition and understanding of public health and its role has changed continuously over time, often affected by current events and the perceived needs for health protection and disease prevention. Starting with early civilization, communities recognized that polluted water and lack of proper waste disposal spread communicable diseases and religions attempted to regulate behavior that specifically related to health, from types of food eaten, to regulating certain indulgent behaviors, such as drinking alcohol or sexual relations.

The role of public health evolved with advanced civilization and the reduced threats of common infectious diseases to address problems associated with risky behaviors and new technology and their accompanying challenges; examples include: smoking, injury related to motor vehicle accidents and firearms, wars and civil conflicts, famine and malnutrition, migration and displaced populations, obesity, unplanned pregnancies and induced abortions, new infectious diseases not encountered earlier (HIV/SARS, West Nile Virus/Hunta Virus), and emergency preparedness to deal with natural and man-made threats and hazards. Over the past few decades, we witnessed an evolution of public health to respond to these emerging challenges accompanied with an increased interest in the development of a better definition of public health and its functions, roles and responsibilities

The main responsibility for public health resides with the departments of health at the local, state or national levels, the success of public health depends on the coordination of efforts and collaboration between these departments and workers in other components of the health care system, other government agencies, community-based organizations, as well as private organizations. The success of the health care systems is the shared responsibility of many sectors of the private and public sectors.

HEALTHCARE REGULATION IN UNITED STATES

Regulation plays a major role in the health care industry and health care insurance coverage. The

various regulatory bodies protect the public from a number of health risks and provide numerous programs for

public health and welfare. Together, these regulatory agencies protect and regulate public health at every level.

Here are five regulations, not all of which are in the spotlight, that can affect delivery and administration of healthcare in the United States on a daily basis:

1. HIPAA. Originally enacted to protect health insurance coverage for workers who lost or changed jobs, the Health Insurance Portability and Accountability Act of 1996 is now most associated with the privacy of patient healthcare information. Under HIPAA, the Department of Health and Human Services (HHS) establishes boundaries on the use and release of health records. It also outlines safeguards to protect patients’ information and establishes civil and criminal penalties for violations. The law applies not just to hospitals and medical practices but also to chiropractors, dentists, nursing homes, pharmacies, and psychologists, as well as to business associates such as third-party administrators, pharmacy benefit managers for health plans, billing and transcription companies and professionals performing legal, accounting, or administrative work.

2. The HITECH Act. The Health Information Technology for Economic and Clinical Health (HITECH) Act, was signed into law in February 2009 to promote the “adoption and meaningful use of health information technology,” according to the HHS website. It mandates audits of healthcare providers to determine whether they are in compliance with HIPAA privacy rules related to privacy and security rules.

The HITECH Act has been called the teeth and claws of HIPAA. Because healthcare records, unlike credit cards, can’t be canceled, changed, or reset in the event of a breach, healthcare providers have increasingly become the target of hackers.

3. MACRA. The Medicare Access & CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 addresses payment for doctors as well as cost controls for Medicare Part B. Part of an overall shift to value-based reimbursement, MACRA moves away from the Sustainable Growth Rate (SGR) payment formula and toward a treatment model based on quality of care and use of EHRs by the medical practice or facility.

4. Medical Necessity. Medical necessity is one of the most important aspects of contemporary healthcare administration, even though it has no regulatory definition at the federal level or in the majority of states. The concept of medical necessity states that if a treatment is not medically necessary, the payer – generally an insurance company, but also Medicare or Medicaid – won’t cover the cost.

5. Chain of Custody. A “Chain of Custody” form, also known as a CCF or CoC, refers to “ a document or paper trail showing seizure, custody, control, transfer, analysis, and disposition of physical and electronic evidence of a human specimen test,” according to the American Alliance Drug Testing website, which details Department of Transportation (DOT) drug testing procedures. The CCF is considered a legal document and can be invalidated if the specimen shows evidence of tampering.