Question

Perform a literature review on a barrier that needs to be addressed in the improvement of health care. Provide an overview of one article related to the health care issue "lack of insurance and underinsurance."

Answer 1

a)  barriers that needs to be addressed in the improvement of health care. are'

Rising Costs

Health care costs have risen over the past several decades in part because of the introduction of new technology or the expanded use of existing technology. Efforts to contain costs by reducing utilization can lead to reductions, appropriate or not, in the use of all types of services, thus threatening the development and diffusion of new and necessary technology. To the extent that underuse of necessary and appropriate technology leads to adverse outcomes, the problem of underuse is as important as any other problem in medicine today. In this context, underuse generally means that the benefits of a procedure for a patient outweigh its risks, that it would be improper not to provide the service, and that the procedure will benefit the patient in a substantial way. This emphasis on underuse should not be construed as minimizing the negative effects of overuse and misuse on health care costs, insurance premiums, access to care, and the quality of care.

USE OF TECHNOLOGY

Health care expenditures are projected to increase by 7.1 percent and 9.9 percent in fiscal years 2001 and 2002, respectively, and to exceed $1.5 trillion in 2002. Between 1940 and 1990, medical technology was estimated to account for about half the growth in real per capita health care expenditures. For inpatient care in fiscal year 2001, the Medicare Payment Advisory Commission estimated that new technology would add 0.5 to 1.0 percent to hospital operating budgets. For outpatient care, Congress believed that routine updating of base-line 1996 data for Medicare would not adequately reflect the additional costs of reasonable or necessary careand therefore provided additional payments for certain forms of technology, beyond the payments associated with the Ambulatory Payment Classification groups for Medicare patients.

Drugs and devices account for a large part of these cost increases. The costs for prescription drugs alone increased by 17.4 percent in 2000, and the Centers for Medicare and Medicaid Services has predicted an average annual increase of 11.3 percent from 2002 to 2010. The fields of interventional cardiology and imaging sciences have both grown rapidly. The number of coronary interventions performed more than doubled from 1983 to 1998, and the percentage of angioplasty cases in which stents were used increased from 50 percent in 1997 to “the overwhelming majority of percutaneous coronary revascularization procedures” in 2000.Expenditures for imaging among Medicare beneficiaries rose at a compounded annual growth rate of 7 percent from the mid-1980s to the late 1990s. Some radiology groups experienced increases of 15.4 to 17.4 percent in utilization between 1998 and 1999 in several high-cost areas, such as computed tomography, magnetic resonance imaging (MRI) and magnetic resonance angiography, nuclear medicine, and nuclear cardiology.62 Although PET has thus far been a small component of these expenditures, that situation will change soon; also, the use of PET and MRI to monitor drug development and therapy is just beginning.In 2000, about 300,000 PET scans were performed, and this number is expected to grow by a factor of more than three within five years; the installation of dedicated PET units is expected to grow by nearly 40 percent per year over the next six years.

UNDERUSE

Underuse of medical technology has been a problem for years, and in many cases adverse outcomes have been either formally documented or intuitively obvious. In the area of primary prevention, relatively inexpensive services such as mammography and Pap smears are frequently underused. Underuse of drug therapy for asthma, depression, and chronic cardiovascular disease is also well documented. Underuse of beta-blockers after an acute myocardial infarction and inappropriate use of calcium-channel blockers have been associated with increased rates of rehospitalization, death, or both.

With the use of an approach developed by RAND, underuse of expensive procedures and devices has also been documented. Cardiac catheterization was not performed in percent to 60 percent of patients for whom it was deemed appropriate, and associated adverse sequelae, particularly increased mortality, have been broadly demonstrated. In the case of revascularization, surgery or angioplasty was not performed in about 30 percent of patients who were considered candidates for it, and there were adverse outcomes.In particular, among patients who were considered candidates for angioplasty but who received medical therapy instead, there was an increased incidence of angina at 30 days. Among patients who were considered candidates for coronary-artery revascularization but who received medical therapy instead, there was an increased incidence of death and of nonfatal myocardial infarction.

b)

How does lack of insurance affect access to care?

Health insurance makes a difference in whether and when people get necessary medical care, where they get their care, and ultimately, how healthy they are. Uninsured people are far more likely than those with insurance to postpone health care or forgo it altogether. The consequences can be severe, particularly when preventable conditions or chronic diseases go undetected.

Compared to those who have health coverage, people without health insurance are more likely to skip preventive services and report that they do not have a regular source of health care. Adults who are uninsured are over three times more likely than insured adults to say they have not had a visit about their own health to a doctor or other health professional’s office or clinic in the past 12 months. They are also less likely to receive recommended screening tests such as blood pressure checks, cholesterol checks, blood sugar screening, pap smear or mammogram (among women), and colon cancer screening. Part of the reason for poor access among the uninsured is that half do not have a regular place to go when they are sick or need medical advice, while the majority of insured people do have a regular source of care.

Uninsured people are more likely than those with insurance to report problems getting needed medical care. One in five (20%) uninsured adults say that they went without needed care in the past year because of cost compared to 3% of adults with private coverage and 8% of adults with public coverage. Many uninsured people do not obtain the treatments their health care providers recommend for them. In 2017, 19% of uninsured adults said they delayed or did not get a needed prescription drug due to cost, compared to 14% with public coverage and 6% with private coverage. And while insured and uninsured people who are injured or newly diagnosed with a chronic condition receive similar plans for follow-up care from their doctors, people without health coverage are less likely than those with coverage to obtain all the recommended services.

Because uninsured people are less likely than those with insurance to have regular outpatient care, they are more likely to have negative health consequences. Because uninsured patients are also less likely to receive necessary follow-up screenings than their insured counterparts,they have an increased risk of being diagnosed at later stages of diseases, including cancer, and have higher mortality rates than those with insurance. In addition, when uninsured people are hospitalized, they receive fewer diagnostic and therapeutic services and also have higher mortality rates than those with insurance.

Uninsured children also face problems getting needed care. Uninsured children are more likely to lack a usual source of care, to delay care, or to have unmet medical needs than children with insurance .Further, uninsured children with common childhood illnesses and injuries do not receive the same level of care as others and are at higher risk for preventable hospitalizations and for missed diagnoses of serious health conditions.Among children with special health care needs, those without health insurance have worse access to care than those with insurance.

Lack of health coverage, even for short periods of time, results in decreased access to care. Research has shown that adults who experience gaps in their health insurance coverage are less likely to have a regular source of care or to be up to date with blood pressure or cholesterol checks than those with continuous coverage Research also indicates that children who are uninsured for part of the year have more access problems than those with full-year coverage. Similarly, adults who lack insurance for an entire year have poorer access to care than those who have coverage for at least part of the year, suggesting that even a short period of coverage can improve access to care.

Research demonstrates that gaining health insurance improves access to health care considerably and diminishes the adverse effects of having been uninsured. A seminal study of a Medicaid expansion in Oregon found that uninsured adults who gained Medicaid coverage were more likely to have an outpatient visit or receive a prescription and less likely to have depression or stress in the short term than their counterparts who did not gain coverage. Findings two years out from the expansion showed significant improvements in access, utilization, and self-reported health among the adults who gained coverage. In addition, a large body of research on the impact of Medicaid expansion under the ACA demonstrates that gains in Medicaid coverage positively impact access to care and utilization of health care services.Research also shows that individuals who gained marketplace coverage in 2014 were far more likely than those who remained uninsured to obtain a usual source of care and receive preventive care services.

Public hospitals, community clinics and health centers provide a crucial health care safety net for uninsured people; however, the safety net does not close the access gap for the uninsured. Safety net providers, including public and community hospitals, community health centers, rural health centers, and local health departments, provide care to many people without health coverage. In addition, nearly all other hospitals and some private physicians provide some charity care. However, safety net providers have limited resources and service capacity, and not all uninsured people have geographic access to a safety net provider.The ACA has led to significant growth in the number of health centers and their service capacity through both new grant funds and new patient revenues due to expanded coverage.However, this impact has been more limited in states not expanding Medicaid, where a much larger share of health center patients remains uninsured than in states that did expand. In addition, health centers in all states report that securing needed specialty care for their uninsured patients is a major challenge.