HEALTH CARE IN THE UNITED STATES Health Care in the United States combines an explanation of population health with a comprehensive introduction to health services delivery. e author, an expert on health care policy and management, shows how the U.S. health services system is organized, managed, fi nanced, and evaluated. Filled with numerous examples and tables, this important resource illustrates key concepts, trends, and features of the system. It places special emphasis on recent health care reform legislation and its implications for the future. Health Care in the United States reviews the historical origins of health care, its resource requirements, costs, quality, and contributions to both individual and social well-being. By combining basic concepts in population health with coverage of health services, the book off ers extraordinary breadth of informa- tion in a highly accessible, easy-to-read text. Along with an in-depth look at the origins and possible impact of recent health reform legislation, the book explains the ongoing dilemmas that face the health care system and highlights health and disease in the modern world, the fundamentals of epidemiology, and health behavior. Health Care in the United States also explains the special challenges of managing health service personnel and organizations. e author reviews key innovations in fi nancing and delivery, explaining the outcomes of cost sharing, HMO enrollment, and rationing of services. is vital resource is written for students and professionals in health care management and policy, as well as public health, medical sociology, medical anthropology, social work, political science, and most, if not all, clinical fi elds. e Author Howard P. Greenwald, Ph.D., is professor of management and policy in the School of Policy, Planning, and Development, University of Southern California, Los Angeles. He also is clinical professor, Department of Health Services, School of Public and Community Health, University of Washington, Seattle and a consultant in health care, organizational eff ectiveness, and program evaluation. Cover design by Mike Rutkowski www.josseybass.com PUBLIC HEALTH/HEALTH SERVICES HEALTH CARE IN THE UNITED STATES HEALTH CARE IN THE UNITED STATES HOWARD P. GREENWALD GREENWALD ORGANIZATION, MANAGEMENT, AND POLICY fbetw.indd xfbetw.indd x 2/10/10 1:49:56 PM2/10/10 1:49:56 PM HEALTH CARE IN THE UNITED STATES Organization, Management, and Policy HOWARD P. GREENWALD ffirs.indd iffirs.indd i 2/10/10 1:45:41 PM2/10/10 1:45:41 PM Copyright © 2010 by John Wiley & Sons, Inc. All rights reserved. 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Printed in the United States of America first edition ISBN 9780787995478 HB Printing 10 9 8 7 6 5 4 3 2 1 ffirs.indd iiffirs.indd ii 2/10/10 1:45:43 PM2/10/10 1:45:43 PM CONTENTS Tables and Figures vii Preface xi The Author xv Acknowledgments xvi PART ONE THE SYSTEM AND ITS TASKS 1 1 UNDERSTANDING HEALTH CARE 3 Health Care as a National Concern 4 Health Care Objectives and Goals 8 Essential Challenges in Health Care 9 Public Trust and Professional Ethics 13 Three Perspectives on Management and Policy 15 2 THE U.S. HEALTH CARE SYSTEM: FEATURES, DEVELOPMENT, AND CONTROVERSIES 19 The U.S. Health Care System’s Magnitude 20 Uniqueness of the System 20 American Values and Health Care 29 Controversies in U.S. Health Care 35 3 MAJOR HEALTH PROBLEMS IN MODERN SOCIETY 41 Conceptions of Health and Disease 42 The Causes of Disease 49 Nondisease Threats to Health, Function, and Survival 55 Epidemiology: The Science of the Denominator 56 Health and Illness in the Twenty-First Century 62 Future Threats to Health 68 ftoc.indd iiiftoc.indd iii 2/10/10 1:46:32 PM2/10/10 1:46:32 PM 4 HUMAN BEHAVIOR, HEALTH, AND HEALTH CARE 71 The Behavioral Dimension 72 The Concept of the Sick Role 72 Health Risk Behavior 73 Use of Health Services 83 Adverse Patient Behavior 88 Health Literacy and Cultural Competence 90 Complementary and Alternative Medicine 94 Consumer Preferences and Health Care Marketing 97 PART TWO MEANS OF DELIVERY 101 5 HEALTH CARE ORGANIZATIONS 103 The Importance of Organizations in Health Care 104 Health Service Industry Sectors 105 Ambulatory Care Organizations 110 The Hospital 116 The Managed Care Organization 128 Other Health Care Organizations 130 Organizational Management in Health Care 135 6 THE HEALTH CARE LABOR FORCE 139 Health Care Labor Force Issues 140 The Concept of Professionalism 141 History, Background, and Challenges in Three Key Fields 143 Clinicians as Managers 154 The Health Care Labor Force: Facts and Figures 155 Labor Force Dynamics in the Health Professions 160 Professional Ethics, Oversight, and Discipline 165 7 HEALTH CARE EXPENDITURES, FINANCING, AND INSURANCE 171 Health Service Funding and Expenditures 172 Health Care Costs: A Global Issue 173 Cost Accelerators in the United States 175 Health Insurance 178 iv Contents ftoc.indd ivftoc.indd iv 2/10/10 1:46:32 PM2/10/10 1:46:32 PM Contents v Additional Insurance Concepts and Terminology 192 Medicare Specifi cs and Issues 194 The Problem of Uninsurance 197 Continuing Issues 201 8 BIOMEDICAL RESEARCH AND PROGRAM EVALUATION 207 The Importance of Research 208 Principles of Experimental Design 209 Modern Research Designs 211 Program Evaluation 218 Cost-Effectiveness and Cost-Benefi t Analysis 221 The Social and Economic Context of Research 221 Science Gone Wrong: Error, Distortion, and Fraud 226 PART THREE PATHS FORWARD 231 9 IMPACT OF INNOVATION: UTILIZATION, COST, AND QUALITY OF CARE 233 Health Service Innovations: Strategic and Tactical 234 Innovations and Health Service Objectives 235 Outcomes of Strategic Innovation I: Selective Contracting 242 Outcomes of Strategic Innovation II: Cost Sharing 244 Outcomes of Strategic Innovation III: Managed Care 247 Outcomes of Tactical Innovations 250 10 HEALTH PROMOTION AND DISEASE PREVENTION 255 The Appeal of Prevention 256 The Scientifi c Rationale for Prevention 257 Prevention in Practice 266 Challenges to Prevention 272 Does Prevention Save Money? 281 The Future: Prevention and U.S. Health Care 285 11 GOVERNMENT, POLICY, AND POLITICS IN HEALTH CARE 289 Government and Health Care in the United States 290 Government Participation in Health Care 294 ftoc.indd vftoc.indd v 2/10/10 1:46:33 PM2/10/10 1:46:33 PM vi Contents The Public Environment 302 The Meaning of Public Policy 303 Politics: The Driver of Public Policy 304 Winning and Losing in Health Care Politics: Three Case Studies 310 Lessons Learned 316 The Case Against Government in Health Care 318 12 CHOICES FOR THE FUTURE 323 Opportunities and Barriers to Change 324 Non-U.S. Health Care Systems: Challenges and Lessons Learned 325 A System to be Emulated? Concerns about Canada 329 State-Level Initiatives in the United States 333 Recent Health Care Reform Efforts 334 Future Controversies and Options 336 Glossary 341 Notes 349 Index 369 ftoc.indd viftoc.indd vi 2/10/10 1:46:33 PM2/10/10 1:46:33 PM TABLES AND FIGURES TABLES 1.1 Age-adjusted deaths per 100,000 U.S. residents, by gender, race, and education 2.1 Population-specifi c health care subsystems in the United States 2.2 Some milestones in the development of the U.S. health care system 2.3 The impact of social values and political culture on U.S. health care 3.1 Major ICD categories and codes 3.2 Nondisease causes of death in the United States, 2004 3.3 The most frequent causes of mortality in the United States, 2005 3.4 The most frequent reasons for offi ce visits in the United States, 2006 3.5 Leading discharge diagnoses from U.S. short-stay hospitals, 2004 4.1 Major health risks by demographic characteristics 4.2 Number and rate (per 100,000 workers) of traumatic occupational fatalities by industry, 2006 4.3 Percentage utilizing health care and dental services in past twelve months by major demographics 4.4 Factors in the Behavioral Model of Health Care Utilization 4.5 Frequency of use of complementary and alternative medicine (CAM), United States, 2002 5.1 Distribution of hospital beds and occupancy rates in the United States, 2006 5.2 Percentage of U.S. children and adults with two or more emergency department visits, 2006 5.3 Types of managed care organizations 5.4 Mental health organizations, beds, and beds per 100,000 civilian population in the United States, 1986 and 2004 6.1 Number of active physicians in the United States, income, and income change from preceding year, by specialty, 2004 6.2 Number of U.S. nonphysician health professionals and income, by profession, 2006 fbetw.indd viifbetw.indd vii 2/10/10 1:49:54 PM2/10/10 1:49:54 PM viii Tables and Figures 6.3 Growth of the health professions, late twentieth century: active personnel per 100,000 population 6.4 Compensation for selected executive positions, University of California, San Francisco, Medical Center, 2005 (excluding bonus) 7.1 Percentages of individuals under age sixty-fi ve with selected sources of health insurance 7.2 Percentage contributions to health care funding by form of insurance, all U.S. residents 7.3 Medicare parts A through D: benefi ts and costs to consumer 7.4 Selected categories of high uninsurance, 2003 7.5 Reasons for not having health insurance among working Latinos in California 8.1 Pasteur’s 1881 anthrax experiment as a fourfold table 8.2 Types of research methodology, applications, and validity 8.3 Outcome indicators widely used in biomedical research 9.1 Structure, process, and outcome measures of health care: selected examples 9.2 Impact of cost sharing on quality of care and patient outcomes 9.3 Impact of HMO membership on quality of care and patient outcomes 10.1 Clinical prevention services according to USPSTF grade (adults), 2008 10.2 Cost-effectiveness and cost impact of selected prevention measures 10.3 Costs and benefi ts per pack of cigarettes 11.1 Comparison of free-market and actual market conditions in health care 11.2 Major U.S. health policies, intended impact, and unanticipated outcomes 12.1 Types of non-U.S. health care systems 12.2 Life expectancy and infant mortality in Canada and the United States 12.3 Percentage who receive treatment for selected chronic conditions in Canada and the United States FIGURES 1.1 Growth in the cost of health care in the United States, 1960–2005 1.2 Survival curves by age for U.S. women in 1900 and 1995 1.3 U.S. health care (greatly simplifi ed): an imperfectly integrated system fbetw.indd viiifbetw.indd viii 2/10/10 1:49:55 PM2/10/10 1:49:55 PM [...]... that they might lose their health insurance if the economy continued to slide Despite the resources allocated to health care in the United States, observers have expressed doubts regarding the value Americans get in return Although the United States ranks highest in the world in per capita expenditures, it has an infant mortality rate higher than most other wealthy industrialized countries Singapore, the. .. highlight the importance of public trust and professional ethics ■ To frame health care issues within three perspectives: a systems approach, critical thinking, and the public interest 4 Understanding Health Care HEALTH CARE AS A NATIONAL CONCERN Health and health care are subjects in which everyone has an interest When young mothers get together, talk soon turns to the health of their children In search... generations as a model for the United States, today faces severe challenges due to increasing health care costs and deteriorating facilities and services The problems and issues covered in this book, then, are likely to remain important in the United States for many generations This book is intended to help readers see their own specialized area of the health care system in the perspective of the whole It covers... crosspurposes Hospitals and insurance companies, for example, are viewed as adversaries, at best communicating inefficiently with each other Acknowledging the absence of 16 Understanding Health Care a tightly run system, this text interchangeably uses the terms health care system and health care industry However, it makes sense to think of health care in the United States as a poorly integrated system Patients... practices do not reflect the principles of evidence-based medicine but rather tradition, their most recent experience, what they learned years ago in medical school or what they have heard from their friends.”10 Recently, health care in the United States has come under increasing criticism owing to issues of social justice The health care system serves the nation unevenly Inequality prevails among... today, the layperson views health care with varying degrees of awe, uncertainty, and suspicion As experienced by many in the modern world, the outcomes of health care are uncertain, the cost unjustifiable, and the practitioners aloof The U.S health care system shares many of the essential characteristics of health care throughout history and across the globe But the U.S system is unusual in the degree... States has steadily increased, from 69.6 years in 1955 to 75.8 years in 1995, and to 77.9 years in 2005.1 Health care, however, has become a major source of dissatisfaction and controversy in the United States A challenge affecting the United States as a whole, and Americans as individuals, is that of cost As Figure 1.1 indicates, the cost of health care increased markedly during the late twentieth... AND POLICY The issues raised in this chapter are likely to appear wherever health care is practiced Some will likely remain important in the United States, even if the mechanisms of financing and delivery fundamentally change Practitioners involved in the delivery of health services will continue to deal with intractable dilemmas and irresolvable public debates Within these limits, the United States can... for Health Administration Studies, which, beginning in the mid-1970s, introduced me to the field of health administration and policy From outstanding figures in this field, including Ronald Andersen, Odin Anderson, Theodore R Marmor, and Selwyn W Becker, I was privileged to receive an incredible volume of facts and an understanding of the discipline Emory B (“Soap”) Dowell, a preeminent member of the. .. at promoting effective action in developing and operating a health care system that serves Americans well Three principles are proposed for achieving this goal: (1) seeing individual roles, interactions, and institutions in health care as parts of a broader system; (2) taking a critical approach to widely shared views among policy makers and the public; and (3) viewing health care as linked inextricably . HEALTH CARE IN THE UNITED STATES Health Care in the United States combines an explanation of population health with a comprehensive introduction to health services delivery U.S. Health Care 285 11 GOVERNMENT, POLICY, AND POLITICS IN HEALTH CARE 289 Government and Health Care in the United States 290 Government Participation in Health Care 294 ftoc.indd vftoc.indd. PUBLIC HEALTH/ HEALTH SERVICES HEALTH CARE IN THE UNITED STATES HEALTH CARE IN THE UNITED STATES HOWARD P. GREENWALD GREENWALD ORGANIZATION, MANAGEMENT, AND POLICY fbetw.indd xfbetw.indd x 2/10/10