Personal Health Services Health Article

ACCESS TO HEALTH SERVICES

Whatever the content and nature of personal health services within a society, an important dimension is access to that care. "Access" not only implies that individuals and families can easily avail themselves of necessary services for preventive and curative reasons, but also that these services will be used appropriately; and not overused. There can be many barriers to personal health care. The most important are economic barriers, and most countries have made some attempts to minimize these. However, many other actual or potential barriers exist, including poor geographic access, particularly in rural and inner city areas; cultural barriers, in both communication and treatment beliefs, between patients and professionals; inadequate transportation to care sites; and long delays in receiving care once within the care setting.

THE CONTINUING EVOLUTION OF PERSONAL HEALTH SERVICES

The nature and organization of personal health services, as with other social activities, is in constant evolution. While many of the types of services have been mentioned above, it is useful for historical and rhetorical purposes to describe their continuing evolution, beginning with the base period of the mid nineteenth century, and noting trends and forces that have shaped today's health care system. Many forces shape personal health services, and their relative roles are sometimes difficult to discern. In general, nineteenth-century prototypic Western medicine can be thought of as a loosely bound set of individual practitioners dealing with individual patients on a "retail" basis. Medicine in this period has been described as a "cottage industry." Payment for care was almost entirely the patient's and family's burden. Institutional care existed, but mostly for small numbers of patients with mental illness or communicable diseases. Hospitals were often church-operated and were largely dedicated to persons with incurable, progressive, and terminal illnesses. However, nearly all births and deaths took place in the home. Health care then began to evolve due to a variety of important forces.

Incorporation of Science and Technology. The continuing injection of scientific discoveries and technological innovations has changed health care dramatically. It has allowed a much more detailed understanding of the causes and pathogenesis of many diseases and conditions, as well as a substantial increase in illness cure and remediation—a great triumph of the twentieth century. These advances have also fostered tremendous shifts in the nature of personal health services. For example, rapidly advancing medical knowledge has led to the need for professional specialization and an elaboration and extension of professional training programs to achieve more enlightened approaches to treating specific and complex health problems. However, the injection of science and technology has had effects viewed by many as adverse, including the role of specialization in fragmenting health-services delivery, the creation of new and serious adverse effects of some therapies, such as malignancies caused by diagnostic and therapeutic radiation, and the large increase in personal health care costs, sometimes for gains viewed as marginal. There have also been environmental threats, such as those due to inadequate medical-waste disposal. Some new health care technologies, as noted above, have also caused moral and ethical dilemmas that defy easy solutions.

The continued application of science and technology has itself become more formalized. While scientific findings have always been translated into clinical practice, more recently there has been an increasing interest in, and new methods for, summarizing published scientific literature. These techniques include meta-analysis, a formal analytical combination of data from multiple studies of a given topic. Increased attention to published, peer-reviewed, scientific findings has led to evidencebased medicine, a philosophy and method of practice that emphasizes translating summarized scientific findings into clinical decision-making.

Insurance and Other Payment Systems for Clinical Care. Before the late nineteenth century, personal health care was generally paid for by patients and their families, supplemented to some extent by charity care from religious and other philanthropic organizations. Governments provided little health care except for the military and special groups in their charge. As the promise of medical care grew, private organizations, beginning with guilds and labor unions, instituted health insurance to pay for the more complex, expensive care—often related to hospitals. These programs eventually grew into the large health insurance industry that exists today. Simultaneously, governments began to fund more personal health services, often beginning with attention to maternal and child health services and indigent care. Most Western governments also began to provide direct health services, using such mechanisms as community health centers, clinics managed by public health agencies, and the provision of health professionals to communities lacking access to health services. Western governments currently fund a broad range of personal health services, ranging from the provision of nearly all health care, such as in the United Kingdom, to care for only certain segments of the population, such as in the United States, where all levels of government pay over 40 percent of national health care costs. In all cases, these funds come largely from general taxation and employer-employee taxes. Overlying these practices are the professed moral imperatives of providing basic health care to all citizens.

The Increasing Organizational Complexity of Personal Health Care Delivery. Simultaneously with advancing and diverse payment systems for care, there has been a companion growth in larger and more complex organizational forms of personal care delivery. Beginning with small groups of physicians and others joining in common administrative units (group practice), there has been a gradual development of large, complex medical-delivery organizations, ranging from nonprofit cooperatives to for-profit national and multinational corporations. These growing administrative entities may own all the service-delivery components and employ health professionals, or they may work through complex contractual arrangements with physicians, patient groups, insurers, employee/employer organizations, and government agencies. These entities usually have an explicit set of services (the "benefit package"), which are prepaid from various sources; and they may profess to emphasize preventive services (the "health maintenance organization"); but most systems have come under the heading of "health plans" or "managed care." In some situations, managed-care organizations are structured or regulated to compete with each other in an attempt to use market forces to control health care costs. Very few clinical practices are free of some form of managed care or superimposed administrative and regulatory authority.

It is difficult to summarize the effects of corporatization on personal health care, and all health care organizations are constantly reforming themselves. Conceivably, there are several salient strengths for large, tightly administrated care systems. Care costs can be more fully monitored, rationalized, and modulated, and some economies of scale may be present. Quality assurance monitoring—through large information systems, with subsequent interventions—should be facilitated more easily than in multiple, small delivery units. Similarly, the dissemination of evidencebased practice guidelines and continuing professional education programs are likely to be enhanced. Strong liaison with public health programs, such as for surveillance, communicable disease control, and public education, could conceivably enhance these activities when compared to traditional programs working wholly outside of personal care systems. However, there have been criticisms of these systems as well, including inappropriate limitations on the doctor-patient encounter; lack of responsiveness to special community needs; repeated changes in health-system contractors, which promotes discontinuity of care; a lack of competition among plans in many areas; inadequate attention to indigents and others without health insurance; and the avoidance of persons with complex and costly illnesses, such as patients with certain cancers, AIDS (acquired immunodeficiency syndrome), renal failure, or complex rehabilitation needs. Large, consolidated health systems seem to be growing and maturing, however, and a return to small, independent care delivery units is unlikely. Thus, it is necessary for all health-delivery systems to promote continued refinement and efficiency so that societal goals for personal health care can be met.

Consumerism in Personal Health Care. As in other commercial affairs arenas, there has been a substantial impact by health care consumers on the delivery of personal care. This is not new, but the intensity of consumer participation in the care process is increasing. For example, health care organizations have become more responsive to consumer complaints and concerns, and many institutions have ombudsmen to assist patients with perceived service problems. Medical consumers often have places on steering committees or boards of directors, as well as on boards and committees reviewing research proposals for ethical concerns. Patients and others have also had an impact through participation in a variety of community-based organizations and associations, often centering on the concern for a particular illness or type of health service. These organizations work to enhance the amount and quality of patient care, and also participate in the political process to achieve particular goals. Finally, many governmental jurisdictions have laws and regulations that protect elements of consumer rights when participating in health care organizations. The degree to which consumer participation has shaped health care is a matter of dispute, but that some level of enhancement and responsiveness has occurred is clear.

Quality Assurance in the Health Care Setting. While it is likely that most health professionals have always strived for the highest quality of service attainable, modern organizational reforms have added more explicit oversight of the quality of care. These are performed by many different sources, including government-funded organizations and their institutional inspectors, health care insurers, voluntary professional organizations, and health care systems and organizations themselves. Quality assurance takes many forms, including direct monitoring of the care process through record abstraction, assessing health system administrative functions, deriving norms for utilization rates for various elements of care, selecting various index illnesses and procedures for detailed outcome measurement, tracking the health and social problems of health care professionals, monitoring adverse health events due to the care process, and, in some instances, publishing various aspects of hospital and health system performance. Quality assurance programs normally result in both organizational and technical-practice changes, which in general would be the most desired result.

An Emphasis on Prevention. With all the professional, technical, and administrative changes in the delivery of personal health services, there has also been a renewed interest in delivering evidence-based clinical preventive services. In many health care venues, detailed information on patients' prevention histories and needs are collected, and in some places manual or automated reminders assist professionals in the timely delivery of preventive care. Many quality-assurance criteria sets have minimum goals for the proportion of patients who should receive evidence-based preventive interventions. However, preventive and health-promotional services can have substantial attendant costs, and health education and counseling can consume a large amount of professional time. Thus, all health care organizations have had to find efficient and effective ways to deliver preventive care in the context of their professional practices, and this has often been challenging.