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Health Studies
Rhan- Ju Song

HLTC05: Social Determinants of Health Lecture 7 –Doctors, Drugs, and Global Health (Rylko-Bauer and Farmer 2002 Trouiller et al. 2002) Tuesday, October 23, 2012 Current Health Care Issues:  Widening racial, ethnic and class disparities in access to care and health outcomes  Uninsured vs. insured  Questionable quality and safety of services  Rising health care and drug costs  Critical hospital bed shortages  Inability to fill prescriptions  Chronic nursing shortages  ER overloads  Ambulance inefficiency o …future of Medicare/Medicaid?  Public health care - Increasingly scrutinized in US Market-Based Medicine  Transformation into a market-based system (service industry?) shaped by forces of competition, commercialization and corporatization  Manifest in growth of managed care (in US and Canada), drug and biotechnology industries  HMOs (health maintenance organizations)  MCOs (managed care organizations) o More neoliberalized o Used by US and it`s privatized and controlled by TNCs o Based on how much you`re going to pay Market-based Health Care (Rylko-Bauer and Farmer 2002)  Emphasis on prevention and integrated services for enrolled individuals, with the goal of controlling costs through prospective financing of a preset, limited budget o Balance their budget for patients and insured clients o Must stick to the budget o That perspective of strategy was suppose to:  *Lower cost, greater efficiency, better quality care*  Originated in the 1970s  Early HMOs largely local and not-for-profit o Now become privatized for profit  MCOs evolved that placed increasing financial pressures on providers they contracted - through increasing consolidation (mergers, acquisitions) and integration of health care services and products, providing these corporations with major economic and political clout in the health care sector  Accompanied by privatization of health care services (profit)  Introduced “explicit rationing”: by limiting unnecessary use of services (determined by evidence-based guidelines), efficiency in delivery of care is maximized, patients are better off and money is saved o More administration and staff o Meeting budget o Limiting services, unnecessary services o Reduce access and quality of care  Patients and physicians are managed through cost-containment techniques that put strict controls on use of medical services and patients’ choice of doctors & medical options… and offer financial incentives to doctors/hospitals to cut costs, services  Costs, increasing efficiencies, making profits  THEORETICAL GOAL AND MAKE PROFITS  N.B.: in US, evolved amidst welfare reforms (1996) that cut into Medicaid coverage and spending o Evolved at the same time during welfare reform o Private sectors set up Consequences of the Marketization of Medicine  Increase in health care costs/spending, yet poorer quality care o More administration dealing with paper work  Widespread rationing of care based on ability to pay (“non-compliance”, Brenda, AIDS case study) o We offer that service, but now you must pay  Rising number of uninsured (unequal access) o Increasing inequality and access to health care in the US  Worsening health status for many  Ethical dilemmas regarding care o Doctors should be there to help them  OVERALL: Opposite of the intended goal  Greater strain on the “health care safety net” (public hospitals, emergency rooms, community health centers, local health departments, community and teaching hospitals, private physicians who give charity care, school-based health clinics) –which also faced public funding cuts o Facilities that are not costly o Removed choices from a lot of people o Wealth gives you the ability to choose and have better health care o Most people only have public funded charitable sources of health care o Increase strain on these facilities o Happening for the past 30-40 years due to neoliberal economics Consequences of the Marketization of Medicine  Widening disparities in access to care, particularly along race, sex, SES/class lines  Uninsured/inadequately insured: ¼ children, un/underemployed, minorities, elderly, women, rural populations, disabled, homeless o Large chunk of the population is under this problem o Have jobs but they don’t provide health care that`s insured: for old people, minorities, children, etc.  In US: at least 30% of population lack ready access to health care  Has become a major mechanism of structural violence (racism, sexism, social inequality, poverty) o Increasing violence on the body Images  Increasingly today, wealth differential how HMO and organizations are making o Graph shows profit of HMOs is increasing o Drop in profits after 2006 because they increased insurance rates  Doctors make a lot of money 4-5x the average salary o There shouldn’t be profit behind this because doctors make enough money  US has high rate of pay for doctors than other countries, especially when comparing with developing and other developed countries o More money in health care Definitions  “Managed care” o Used in the United States to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care ("managed care techniques") for organizations that use those techniques or provide them as services to other organizations ("managed care organization" or "MCO"), or to describe systems of financing and delivering health care to enrollees organized around managed care techniques and concepts ("managed care delivery systems") o the business sector became involved in promoting managed care as a means of controlling the spiraling costs of health benefits, new forms of for-profit managed care organizations (MCOs) evolved that placed increasing financial pressures on providers with whom they contracted o Introduced explicit rationing: by limiting unnecessary use of services (determined by evidence-based guidelines), efficiency in the delivery of care is maximized, patients are better off, and money is saved o Both patients and physicians are managed through cost-containment techniques that put strict controls on use of medical services and on patients' choice of doctors and medical options and that offer financial incentives to doctors and hospitals to cut costs and services. o Numerous accounts exist of moral and ethical conflicts that managed care structures create when they force doctors to deny patients access to needed care or when they link financial incentives to "productivity" and the rationing of care  “Boutique medicine” A.K.A. “Concierge medicine” o Private, exclusive clinics where you pay extra ($1000-3000-5000) to see a doctor and have more time with them and you’ll get better health care for treatment, drugs, etc. o Based on pay o Seen in Canada as well  concierge medicine a co
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