Essentials of the U.S Health Care System Fourth Edition Leiyu Shi, DrPH, MBA, MPA Professor, Johns Hopkins Bloomberg School of Public Health Director, Johns Hopkins Primary Care Policy Center for the Underserved Johns Hopkins University Baltimore, Maryland Douglas A Singh, PhD, MBA Associate Professor Emeritus of Management School of Business and Economics Indiana University South Bend South Bend, Indiana World Headquarters Jones & Bartlett Learning Wall Street Burlington, MA 01803 978-443-5000 info@jblearning.com www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com Copyright © 2017 by Jones & Bartlett Learning, LLC, an Ascend Learning Company All rights reserved No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product endorsement purposes All trademarks displayed are the trademarks of the parties noted herein Essentials of the U.S Health Care System, Fourth Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product There may be images in this book that feature models; these models not necessarily endorse, represent, or participate in the activities represented in the images Any screenshots in this product are for educational and instructive purposes only Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service If legal advice or other expert assistance is required, the service of a competent professional person should be sought 10066-2 Production Credits VP, Executive Publisher: David D Cella Publisher: Michael Brown Associate Editor: Lindsey Mawhiney Associate Editor: Nicholas Alakel Production Assistant: Rebecca Humphrey Composition: Integra Software Services Pvt Ltd Cover Design: Kristin E Parker Rights & Media Research Specialist: Merideth Tumasz Media Development Editor: Shannon Sheehan Cover Images: Flag: © Feng Yu/ShutterStock, Inc., DC Skyline: © holbox/Shutterstock Inc Printing and Binding: Edwards Brothers Malloy Cover Printing: Edwards Brothers Malloy Library of Congress Cataloging-in-Publication Data Shi, Leiyu, author Essentials of the U.S health care system/Leiyu Shi and Douglas Singh – Fourth edition p.; cm Essentials of the United States health care system Includes bibliographical references and index ISBN 978-1-284-10055-6 (alk paper) I. Singh, Douglas A., 1946-, author. II. Title. III Title: Essentials of the United States health care system [DNLM: 1. Delivery of Health Care–United States. 2. Health Policy–United States W 84 AA1] RA395.A3 362.10973–dc23 201503207 6048 Printed in the United States of America 19 18 17 16 15 10 Contents Preface ix New in the Fourth Edition xi Acknowledgments xiii List of Exhibits xv List of Tables xvii List of Figures xix Chapter Major Characteristics of U.S Health Care Delivery 1 Introduction 1 Subsystems of U.S Health Care Delivery Characteristics of the U.S Health Care System Health Care Systems of Other Developed Countries 19 Systems Framework 23 Conclusion 25 Chapter Foundations of U.S Health Care Delivery 29 Introduction 29 What Is Health? 30 Determinants of Health 33 Cultural Beliefs and Values 36 Distribution of Health Care 37 Strategies to Improve Health 41 Conclusion 48 iv Contents Chapter Historical Overview of U.S Health Care Delivery 53 Introduction 53 Medical Services in Preindustrial America 55 Medical Training 56 Medical Services in Postindustrial America 59 History of Health Insurance 64 Medical Services in the Corporate Era 72 Era of Health Care Reform 74 U.S Health Care Today 76 Conclusion 77 Chapter Health Care Providers and Professionals 81 Introduction 81 Physicians 83 Dentists 91 Pharmacists 92 Other Doctoral-Level Health Professionals 93 Nurses 95 Nonphysician Practitioners 97 Allied Health Professionals 99 Public Health Professionals 101 Health Services Administrators 102 Conclusion 103 Chapter Technology and Its Effects 107 Introduction 107 What Is Medical Technology? 109 Health Information Technology 110 Diffusion and Utilization of Medical Technology 114 The Government’s Role in Technology Diffusion 117 Impact of Medical Technology 122 Assessment of Medical Technology 127 Benefits of Technology Assessment 129 Conclusion 130 Chapter Financing and Reimbursement Methods 135 Introduction 135 Effects of Health Care Financing and Insurance 137 Insurance: Its Nature and Purpose 139 Private Insurance 141 Contents v The Affordable Care Act and Private Insurance 145 Public Insurance 147 The Affordable Care Act and Public Insurance 155 Reimbursement Methods 156 The Affordable Care Act and Payment Reform 160 National Health Expenditures 161 Conclusion 163 Chapter Outpatient Services and Primary Care 167 Introduction 167 What Is Outpatient Care? 168 Scope of Outpatient Services 168 Outpatient Care Settings and Methods of Delivery 171 Primary Care 176 Effectiveness of Primary Care 181 The Medical-Home Strategy 185 Assessment of Community Health Centers 185 Conclusion 187 Chapter Hospitals 193 Introduction 193 Evolution of the Hospital in the United States 194 Expansion and Downsizing of Hospitals in the United States 196 Access and Utilization Measures 200 Hospital Employment 202 Types of Hospitals 202 The Affordable Care Act and Hospitals 210 Licensure, Certification, and Accreditation 210 Hospital Organization 211 Ethics and Public Trust 212 Conclusion 215 Chapter Managed Care and Integrated Systems 219 Introduction 219 What Is Managed Care? 220 Evolution of Managed Care 222 Growth and Transformation of Managed Care 225 Utilization Control Methods in Managed Care 227 Types of Managed Care Plans 229 vi Contents Impact on Cost, Access, and Quality 234 Integrated Systems 236 Types of Integration 238 Managed Care and Organizational Integration Under the Affordable Care Act 241 Conclusion 241 Chapter 10 Long-Term Care Services 245 Introduction 245 What Is LTC? 247 Community-Based Long-Term Care Services 253 Institutional Long-Term Care 257 Licensing and Certification of Nursing Homes 261 Other Long-Term Care Services 263 The Affordable Care Act and Long-Term Care 264 Nursing Home Industry and Expenditures 264 Conclusion 266 Chapter 11 Populations with Special Health Needs 269 Introduction 269 Framework to Study Vulnerable Populations 270 Predisposing Characteristics 271 Enabling Characteristics 279 Eliminating Socioeconomic Disparities 281 Need Characteristics 283 Conclusion 286 Chapter 12 Cost, Access, and Quality 291 Introduction 291 Cost of Health Care 292 The High Cost of U.S Health Care 293 Reasons for High Health Care Costs 296 Cost Containment 298 Unequal in Access 301 Average in Quality 306 Quality Strategies and Initiatives 310 Developments in Process Improvement 311 Conclusion 312 Contents vii Chapter 13 Health Policy 317 Introduction 317 What Is Health Policy? 318 Principal Features of U.S Health Policy 320 Development of Legislative Health Policy 329 Critical Policy Issues 331 International Health Policy: Comparisons 337 Conclusion 338 Chapter 14 The Future of Health Services Delivery 341 Introduction 341 Forces of Future Change 342 Challenges of Coverage, Access, and Cost 346 The Future of Health Care Reform 348 Future Models of Care Delivery 352 Future Workforce Challenges 354 Global Challenges 355 New Frontiers in Clinical Technology 356 Care Delivery of the Future 358 Conclusion 358 Appendix 363 Glossary 367 Index 379 Preface This text is a condensed and simplified version of our standard textbook on the U.S health care system, Delivering Health Care in America: A Systems Approach, Sixth Edition, which has been widely used for teaching both undergraduate and graduate courses While retaining the main themes of the larger book, this version covers the essential elements of U.S health care in an easier to read format This text leaves out much of the data and technical details found in the expanded version Remaining comprehensive and focused, this condensed version is designed for maximum accessibility and flexibility This text retains the systems model to organize the major themes of U.S health care delivery The first three chapters lay the foundation that is necessary for understanding the U.S health care delivery system, which is distinct from any other system in the world “Major Characteristics of U.S Health Care Delivery” (Chapter 1) gives an overview of U.S health care and contrasts the American system with the three most commonly used models of health care delivery in other advanced nations, such as Canada, the United Kingdom, and Germany “Foundations of U.S Health Care Delivery” (Chapter 2) explains the different models for understanding health and its determinants In the context of American beliefs and values, this chapter also discusses the issue of equity using the concepts of mar ket justice and social justice and explains how health services are rationed in both market justice– and social justice–based systems “Historical Overview of U.S Health Care Delivery” (Chapter 3) traces the history of U.S health care from colonial times to the present and includes an added section on health care reform The key to understanding the nature of the Index 387 capacity of, 347 justice in, 40–41 WHO definition of, 31 health disparities, 281 health informatics, 111 health information technology, 110–114 Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, 112 health insurance exchanges, 281, 322 health insurance, history of creation of Medicare and Medicaid, 68–72 emergence and rise of private health insurance, 64 employment-based health insurance, 66 failure of national health insurance in U.S, 66–68 hospital plan and birth of Blue Cross, 65 physician plan and birth of Blue Shield, 65–66 workers’ compensation, 64 health insurance marketplaces, 145 Health Insurance Portability and Accountability Act (HIPAA), 112–113, 328 health insurance rates, 142, 143e health maintenance organization (HMO), 235 carve-outs, 231 difference from PPO and POS plans, 230e federal support of, 319 gatekeeping and, 233 group model HMO, 231–232 growth of, 223 independent practice association model HMO, 232–233 Medicare Advantage and, 150–151 network model HMO, 232 number of, plans, 229–233 reimbursement, 157, 226 staff model HMO, 231 Health Maintenance Organization Act (1973), 223 Health Manpower Act of 1968, 95 health plan, health plan enrollments, distribution of, 142, 142f health planning, 299 health policy allocative tools, 319–320 definition of, 318 different forms of, 318–319 regulatory tools, 319 health professional, 74 health reimbursement arrangement (HRA), 145 health savings account (HSA), 145 health services administrators, 102–103 health technology assessment (HTA), 127–129 benefits of, 129–130 health workers, worldwide shortage of, 345 Healthcare Effectiveness Data and Information Set (HEDIS), 222, 305 Healthy Kids Corporation, 327 Healthy People 2010: Healthy People in Healthy Communities, 41–43, 43f Healthy People 2020 initiative, 282 Healthy People Consortium, 42 heart disease, 124 HEDIS See Healthcare Effectiveness Data and Information Set heredity, as determinant of health, 35 HHRG See home health resource group hidden costs, 15 high-deductible health plans (HDHPs), 144–145 Hill-Burton Hospital Construction Act, 197, 328 HIPAA See Health Insurance Portability and Accountability Act Hispanic Americans, 272, 273e history of medicine in U.S., 194–196, 194e corporate era, 72–74 health care reform, 74–76 health insurance, 64–72 medical training, 56–59 postindustrial era, 55, 59–63 preindustrial era, 55 U.S health care today, 76–77 HITECH Act of 2009 See Health Information Technology for Economic and Clinical Health Act of 2009 HIV/AIDS, 303 access to health care, 331 antiretroviral therapy, cost of, 286 dental care and, 92 drug review process, 119 females diagnosed with, growing number of, 285 subacute care and, 260 technology, effects on, 124 transmission paths, 285–286 HMO See health maintenance organization holism, 85 388 Index holistic medicine, 31 holistic model of health, 31, 251–252 Home and Community Based Services waiver program, 253 home-delivered and congregate meals, 255–256 home health care, 174, 254, 264 home health resource group (HHRG), 160 homebound persons, dental needs of, 92 homelessness, 279–281 homemaker and handyman services, 174, 256 horizontal integration, 240 hospice care, 174, 263–264 Hospital Corporation of America, 206 hospital insurance (HI) (Part A), 65, 148–150 hospital planning, 65 Hospital Survey and Construction Act (1946), 197 hospitalists, 85–86 hospitals access and utilization measures, 200–202 accreditation, 210–211 Affordable Care Act, 210 capacity utilization, 201, 202t certification, 210–211 chief executive officer of, 193–194, 211–212 children’s, 208 community, 201, 203, 203e cost containment and, 334–335 development in postindustrial era, 63 employment in, 202 ethics and, 212–214 evolution of, 194–196, 194e expansion and downsizing of, 196–200, 199e expenditures, hospital/national health comparison, 199f expenses, Medicare share of, 198f factors contributing to growth, 197e general, 207, 210 governance and organization, 211–212, 212f licensure, 210–211 long-term care, 260 osteopathic, 209–210 outpatient clinics, 172–173 overview of, 193–194 private for-profit, 206 private nonprofit, 205–206 psychiatric, 207 public, 203–204 public trust and, 214 rehabilitation, 208 rural, 208–209 specialty, 207 teaching, 62, 158, 177, 209 types of, 202–210, 204f Howard University School of Medicine, 63 HRA See health reimbursement arrangement HSA See health savings account HTA See health technology assessment hypertension, 32, 183, 255, 281 I IADL See instrumental activities of daily living ICF/IID See Intermediate Care Facility for Individuals with Intellectual Disabilities ICF/MR See Intermediate care facility for the mentally retarded IDSs See integrated delivery systems IHRs See International Health Regulations imaging technology, 357 in-home patient monitoring, 114 independent practice association (IPA), 232–233, 240 Indian Health Service, 275e individual-level interventions, 48 individual private insurance, 144 infant mortality, 182, 184, 273e, 274, 275e, 325 infectious diseases, 58, 345 information revolution, 73 information-sharing networks, 111 information technology (IT), 110–114 administrative information systems, 111 clinical decision support systems, 111 clinical information systems, 110–111 decision support systems, 111 electronic health records, 111–113 health informatics, 111 internet and e-health, 111, 113 telemedicine, 73 and remote monitoring, 114 informed consent, 214 Initiative to Eliminate Racial and Ethnic Disparities in Health (1998), 275e Injury and Illness Prevention Program, 46–47 inpatient day, 200 inpatient, defining, 193 Institute of Medicine (IOM), 112, 307 definition of primary care, 177, 178 Future of Public Health in the 21st Century, on tobacco use, 334 Index 389 institutional long-term care, 257–261, 258f, 263 assisted living facilities, 259 personal care facilities, 258–259 as respite care, 263 retirement facilities for, 257–258 skilled nursing facilities, 259–260 specialized care facilities, 260–261 subacute care facilities, 260 instrumental activities of daily living (IADL), 250, 283 insurance coverage, 117, 321 access to health care services based, 18 insurance, health basic concepts, 139–140 Blue Cross/Blue Shield, 2f, 65–66 children’s program, 6, 153–154, 350 coinsurance, 141 copayment, 140 cost sharing, 140–141 deductible, 140 effects of health care financing and, 137–139, 138e employer-based, 66, 142 employment-based, 219–220 first private, 222 group, 143 history of children’s program, 322, 326, 333 employer based health insurance, 66 first hospital plan and birth of Blue Cross, 65 first physician plan and birth of Blue Shield, 65–66 Medicaid and Medicare, creation of, 68–72, 317 national health care, ACA and, 76–77 individual private, 144 managed care and, 144 nationalized, numbers of Americans covered by, in postindustrial era, 64–72 private, 3, 141–145, 222–223 public, 3, 136 self-insurance, 143 insurance risk pool, 327 insured, definition of, 139–140 integrated care, 180 integrated delivery systems (IDSs), 7, 15, 72–73, 237 accountable care organizations, 236 acquisitions, 236 alliances, 239–240 based on major participants, 238 based on service consolidation, 240–241 based on type of ownership or affiliation, 238 horizontal integration, 240 joint ventures, 239 mergers, 239 types of, 238–241 vertical integration, 240–241 virtual organizations, 240 integrated electronic medical records, 48 integrated systems, 24–25 integration, quest for, 18 Interagency Working Group on Environmental Justice, 282 interest groups, 324 politics, 323–324 Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), 262 Intermediate care facility for the mentally retarded (ICF/MR) certification, 262 international health policy, 337–338 International Health Regulations (IHRs), 355 Internet, 109, 113 as source of patient education, 15 interoperability, 111 interventions, health care, 46–48 investor-owned hospitals See private for-profit hospitals IOM See Institute of Medicine IPA See independent practice association IT See information technology item-based pricing, 15 J Johns Hopkins University, 62 Johnson, Lyndon, 69, 328 joint ventures, 239 The Joint Commission, 194, 211 justice, in health care system, 40–41 K Kaiser, Henry J., 223 Kaiser Permanente plan, 223 Kefauver-Harris Amendments, 119 Kerr Mills Act, 69 Kerr-Mills program, 70 390 Index L Latino Americans, 272 legal risks, influence practice behaviors, 18–19 legislative health policy development, 329–331 legislative process, 330–331 licensed practical nurses (LPNs), 95, 259 licensed vocational nurses (LVNs), 95, 259 licensing of nursing homes, 261 life expectancy at birth, 13, 13f income inequality and, 34–35 increase in, 297 rural Americans and, 305 life-extending services, 335 Life Safety Code, 261 life support, 108, 127, 213 lifestyle, as determinant of health, 35 long-term care (LTC), 245–246 Affordable Care Act (ACA) and, 264 assisted living facilities, 259 case management and, 174, 256–257 characteristics of, 247, 248e children in, 245 community-based services, 253–257 continuing-care retirement communities, 257 coordination of services in, 249 definition of, 247 extended period of time, 251 goal of, 250 holistic approach to, 251–252 home health care and, 254 hospice care, 263–264 individualized services, 249 informal, 246 institutional, 257–261, 258f, 263 maximum possible functional independence and, 250–251 nursing homes, 261–263 outpatient services and, 174–175 personal care facilities, 258–259 progression toward need for, 247, 247f quality of life and, 252–253 respite care, 263 restorative care, 263 retirement facilities, 257–258 skilled nursing facilities, 259–260 specialized care facilities, 260–261 subacute care facilities, 260 as subsystem, 7–8 variety of services in, 248–249 young adults in, 245 long-term care hospitals (LTCHs), 260 longevity, 107, 123 low population density, 278 LPNs See licensed practical nurses LTC See long-term care LTCHs See long-term care hospitals Luft, H S., 235 LVNs See licensed vocational nurses M MA-PDs See Medicare Advantage prescription drug plans magnetic resonance imaging (MRI), 109 maintenance rehabilitation, 263 major medical plans, 143 maldistribution, 88–90 defining, 88 geographic, 89, 278 looming shortages and Affordable Care Act, 88–89 specialist, 89–90 malpractice, 298 insurance, 19 managed care, 2f defining, 220 of health care delivery, 3–4 precertification and, 228, 233 reimbursement under, 157 managed care organizations (MCOs), 4, 24, 141, 144, 151 access and, 235 accountable care organizations, 237–238 accreditation and, 221–222 Affordable Care Act (ACA), 241 backlash/response to backlash, 226 capitation (per head) payment, 221, 225, 230 characteristics of, 220–221, 222e competition among, 225 corporatization of health care and, 72–73 cost containment and, 234 defining, 4, 220 evolution and growth of, 220–226 financing of, 220 gatekeeping, 227 health care delivery, 221 health maintenance organization (HMO) plans, 229–233 Index 391 hospital downsizing and, 199 insurance premiums and, 220 integrated systems, 236–237 integration, types of, 238–241 Medicare Advantage and, 150–151 number of enrollees, outpatient clinics, 172 payer-driven price competition and, 301 percentage of employer-based plans as, 142 point-of-service plans, 234 preferred provider organization (PPO) plans, 233 primary care and, 172 private health insurance and, 225 provider payments, 221 public health insurance and, 226 quality indicators, 221–222 quality of care and, 235–236 reimbursement, 157, 220, 226 success of, 220, 226 transformation of, 226 types of plans, 229–234, 230e utilization controls, 227–229 utilization review, 227–229 managed care plans, 144 managed care report cards, 221 market conditions, effect of health care delivery, 13, 15–16 market justice, 16–17, 37–38 principle of, 37–38 versus social justice, 39t U.S health care system as not based on, 40–41 market-oriented reforms, 300 MCOs See managed care organizations MD See doctor of medicine Meals on Wheels program, 248, 256 meaningful use, of EHR technology, 112 means-tested program, 70, 153 mediating factors, 279 Medicaid, 3, 6, 8, 10, 136, 152–153 Affordable Care Act (ACA) and, 351–352 Children’s Health Insurance Program and, 153–154 community health centers and, 175 community hospitals and, 204 creation of, 68–72, 317 dental care and, 92 eligibility, 70, 136, 152–153 expansion under ACA, 146–147, 215, 322 fraud and, 298 gradual reforms of, 322 home health care and, 255 hospital certification and, 211 hospital expansion and, 197–198 hospital utilization and, 201 long-term care and, 254, 264, 265 managed care and, 225, 234, 235 Medicare versus, 70, 71e passage of, 328 program, 70 reimbursement and, 10, 17 state policy and, 326–327 Medicaid Catastrophic Act, 322 Medicaid Data System, 303 Medicaid Demonstration Projects, 303 Medical Assistance Act, 69 medical care, 358 determinants of health, 35–36, 45–46 medical center, 194 Medical Devices Amendments of 1976, 120–121 medical devices, regulation of, 120–121 medical discoveries, groundbreaking, 60, 61e Medical Expenditure Panel Survey (MEPS), 303 medical-home model, 185 medical institutions, 58–59 medical laboratory technicians, 100 medical loss ratio, 220 medical model, 30, 297 medical points of intervention, 46–48 medical practice, 56–57 guidelines, 130, 311 medical profession, 60 medical rationing, 108, 115 medical records, electronic, 48, 110–111 medical services in corporate era, 72–74 in postindustrial America, 59–63 in preindustrial America, 55 medical systems, 196 medical technology, effect of, 344 medical tourism, 74 medical training, 56–59 and practice, about technology, 116 medically underserved areas, 278 Medicare, 3, 6, 8, 10, 342 accountable care organizations (ACOs), 238 Affordable Care Act (ACA) and, 351–352 community hospitals and, 204 392 Index creation of, 68–72, 317 eligibility, 136, 147–148 Federal Hospital Insurance, 351 financing of, 351–352 fraud and, 298 funding (2012–2014), 352t hospital certification and, 211 hospital expansion and, 197–198, 198f hospital insurance (HI), 65, 148–150 hospital utilization and, 201 long-term care (LTC), 7–8, 254, 265 low-income beneficiaries, 148 managed care enrollments and, 225 versus Medicaid, 70, 71e Medicare Advantage (Part C), 150–151, 222, 225, 234 noncovered services, 148 number of enrollees, 4, 139 Patient Self-Determination Act and, 213 peer review and, 300 prescription drug coverage (Part D), 151–152, 321 reimbursement and, 10, 17, 156–160, 299, 335 rules, 237 supplemental coverage, 148 supplementary medical (Part B), 150 Supplementary Medical Insurance Trust Funds, 351 Medicare (Part A), 69, 148, 149f Medicare (Part B), 69–70 Medicare (Part D), 151, 152t Medicare Advantage (Part C), 150–151, 222, 225, 234 Medicare Advantage prescription drug plans (MA-PDs), 151 Medicare Current Beneficiary Survey, 303 Medicare Fee Schedule, 157 Medicare Prescription Drug, Improvement, and Modernization Act (MMA), 151 Medicare Severity Diagnosis-Related Groups (MS-DRGs), 158 Medicare Statistical System, 303 Medicare tax, 137, 148 Medicare+Choice, 150 Medigap, 148, 151 plans, 321 Meharry Medical College, 63 mental care, holistic caregiving, 252 mental health, 283–284 homeless persons and, 279–281 mental illness, 284 MEPS See Medical Expenditure Panel Survey mergers, 239 MERS See Middle East Respiratory Symptom metropolitan statistical area (MSA), 208 Middle East Respiratory Symptom (MERS) virus, 345 middle-level health services administrators, 102 Migrant Health Act (1962), 275e Migrant Health Center Program, 275e migrant health centers, 87, 92, 99, 175 military medical care system, 4–5, 136 Miller, R H., 235 minimally invasive surgery, 124, 357 Minority Health Initiative, 275e mobile facilities, 173 molecular medicine, 356 moral hazard, 138, 164, 296 morbidity gender and, 274 new morbidities, 274 primary care effect on, 183–184 rural Americans and, 305 technology and, 123 mortality death rates by age and cause, 30, 31f eating disorder, 276 income inequality and, 34–35 infant, 182, 184, 273e, 274, 275e, 325 minorities and, 272, 275e primary care effect on, 90, 182, 184–185 rural Americans and, 305 MRI See magnetic resonance imaging MS-DRGs See Medicare Severity Diagnosis-Related Groups MSA See metropolitan statistical area multipayer system, 297 multiple players, health care system, 17 Mutchnick, I S., 74 N NACCHO See National Association of County & City Health Officials nanomedicine, 109 Index 393 National Academy of Sciences, 354 National Ambulatory Medical Care Survey, 168 National Association of County & City Health Officials (NACCHO), 42–43 National Board for Certification in Occupational Therapy, 101 National Board of Podiatry, 94 National Center for Health Services Research, 336 National Center for Health Statistics (NCHS), 285, 293 National Center for Health Workforce Analysis, 89 National Committee for Quality Assurance (NCQA), 221 National Contact Lens Examiners, 101 national debt, 350–351 National Fire Protection Association, 261 national health care costs See national health expenditures National Health Care Workforce Commission, 89 national health expenditures, 161–163, 161t average annual increase, 223, 223f breakdown of, 162f defining, 136, 161 GDP/CPI comparison, 293 gross domestic product (GDP) as measure for, 291 growth comparisons of, 163t hospital expenditures compared with, 199f national health insurance in U.S, 68, 68e failure of, 66–68 National Health Interview Survey (NHIS), 302 National Health Maintenance Organization Census, 305 National Health Planning and Resources Development Act (1974), 328, 335 National Health Service Corps (NHSC), 278, 332, 333 National Institute for Health and Clinical Excellence (NICE), 115 National Institutes of Health (NIH), 122, 318 National Public Health Performance Standards Program, National Quality Strategy, 310 National Rural Health Association, 277–278 National Sample Survey of Registered Nurses, 96, 97 National Surveys of Health Care, 304t nationalized health care, 13, 19 American Medical Association (AMA) opposition to, 67 historical failure in U.S., 66–68 Native Hawaiians, 272 natural disasters, 345–346 NCHS See National Center for Health Statistics NCQA See National Committee for Quality Assurance need attributes, 283 need characteristics, 271e, 283 needs-based model, 89 Netherlands, 338 network model HMO, 232 new morbidities, 277 New Zealand, policy study on, 338 NF certification, 262 NHIS See National Health Interview Survey NHS-England, 21 NHSC See National Health Service Corps NICE See National Institute for Health and Clinical Excellence NIH See National Institutes of Health Nixon, Richard, 299, 328 nonmaleficence, 213 nonphysician practitioner (NPP), 83, 97–99 advanced-practice nurses, 96–97 certified nurse–midwives, 97–99 nurse practitioners, 97–99 physician assistants, 97, 98 value of services, 98–99 nonprofit organizations, tax benefits for, 205–206 NPP See nonphysician practitioner NPs See nurse practitioners nuclear pharmacists, 93 nurse practitioners (NPs), 96–98 nurses, 95–97 future educational needs for, 354 licensed practical nurses, 95, 259 licensure for, 95 registered nurses, 95 shortfall of, 96 nursing homes certification of, 261–263 industry and expenditures, 264–266, 265t, 266t licensing of, 261 394 Index Nursing Training Act (1964), 95 Nursing Training Act (1971), 95 nutrition-support pharmacists, 92 nutritionists, 101 O OASIS See Outcomes and Assessment Information Set Obama, Barack, 54, 75, 76, 328–329, 343 Obamacare, 342, 349 obesity, 182, 184 childhood, 47–48, 277, 278f OBRA See Omnibus Budget Reconciliation Act occupancy rate, hospital, 201 Occupation Safety and Health Act (OSHA), 46–47 goal of, 46 occupational therapists (OTs), 100–101, 174, 263 Office of Minority Health, 275e Office of Research on Women’s Health, 277 Office of the Actuary, 136 Older Americans Act (1965), 253 Omnibus Budget Reconciliation Act (OBRA) of 1989, 300, 336 OPPS See Outpatient Prospective Patient System optometrists/optometric care, 93–95, 94t, 99, 156, 169, 173, 249 reimbursement for, 171 organizational integration, 236 organized medicine, 61 Orphan Drug Act (1983), 118e, 119 orphan drugs, 119 OSHA See Occupation Safety and Health Act osteopathic hospitals, 209–210 osteopathic medicine, 83–85 osteopaths, 169 OTs See occupational therapists out-of-pocket cost, 151, 152e outcome domain, quality of health care, 309–310 outcomes patient, 336 system, 25 Outcomes and Assessment Information Set (OASIS), 160 outpatient care, defined, 168 outpatient, defining, 193 Outpatient Prospective Patient System (OPPS), 159 outpatient services, 187–188 See also primary care alternative medicine clinics, 176 community health centers, 175, 185–187 free clinics, 176 freestanding facilities, 173 home care, 174 hospice care, 174 hospital outpatient clinics, 172–173 long-term care and, 174–175 managed care organizations and, 172 mobile facilities, 173 overview of, 167–168 private practice, 172 public health services, 175 reimbursement, 171 scope of, 168–171 settings and delivery methods, 168e, 171–176 social factors leading to increase in, 171 technologic factors leading to increase in, 171 telephone triage, 173–174 utilization control factors leading to increase in, 171 overutilization, 229, 311 P Pacific Islanders, 272, 273e package pricing, 15, 156 PAHO See Pan-American Health Organization palliative care, 174 Pan-American Health Organization (PAHO), 45–46 Parchman, M L., 183 participatory decision making, 47 Passage of the Affordable Care Act (ACA), social justice and, 29–30 patient days, hospital, 201 patient outcomes research teams (PORTs), 336 Patient Protection and Affordable Care Act (ACA) accountable care organizations and, 237 cost containment and, 335 expansion of Medicaid under, 213, 322 health insurance exchanges and, 322 quality indicators and, 222 uninsured under, 279, 281 patient-provider relationship, 18 Patient Self-Determination Act (1990), 213 patients Index 395 confidentiality issues, 112 empowerment of, 73, 113 informed consent and, 214 quality of life, 33, 124, 253 rights of, 112 payer-driven price competition, 301 payment reform, 160 peer review and cost containment, 300 peer review organizations (PROs), 300 per diem reimbursement rates, 157 per member per month (PMPM), 157, 221, 230 PERS See personal emergency response system personal care facilities, 258–259 personal emergency response system (PERS), 256 personalized medicine, 356–357 pesthouse, 58, 194–195 PHA See Physician Hospitals of America pharmaceutical care, 93 pharmaceutical industry, 115 rational drug design and, 357 Pharmaceutical Research and Manufacturers of America, 324 pharmacists, 92–93, 93t pharmacogenomics, 356–357 pharmacotherapists, 92 PharmD degree, 92 physical aspect, holistic caregiving, 251–252 physical therapists (PTs), 100, 263 physical therapy, 174 assistants, 100 Physician Hospitals of America (PHA), 206 Physician Masterfile, 303 physician-owned hospitals, 210 physician planning, 65–66 Physician Quality Reporting System (PQRS), 310 physician–hospital organization (PHO), 238 physicians doctor of medicine, 83–85 doctor of osteopathic medicine, 83–85 generalists, 85, 180 geographic maldistribution of, 89, 278 hospitalists, 85–86 licensure requirements, 83 maldistribution of, 88–90 MDs and DOs comparison, 84–85 number of active, 84, 84t as office-based practitioners, 172 residency, 84 specialists, 85 specialty maldistribution of, 89–90 work settings and practice patterns, 87, 87t planned rationing, 40 pluralistic groups politics, 323–324 PMPM See per member per month podiatrists, 94, 94t point of entry, primary care as, 178, 178e point-of-service (POS) plans, 234 difference from HMO and PPO plans, 230e policy cycle, 329–330 policy, health care, 317, 338–339 access to care, 331 as allocative tool, 319–320 cost containment, 334–335 critical policy issues, 331–337 decentralized role of states, 326–327 defining, 318 forms of, 318–319 as fragmented/incremental/piecemeal, 321–323 government as subsidiary to private sector, 320–321 international comparisons, 337–338 legislative health policy development, 329–331 pluralistic and interest group politics, 323–324 presidential leadership, effect on, 327–329 principal features of, 320–329 quality of care, 335–336 as regulatory tool, 319 policy interventions, 46–47 polio, 345 political will, 344 poorhouse, 58 population-based surveys, 302 population health, definition of, 34f PORTs See patient outcomes research teams POS See point-of-service plans positron emission tomography, 123 postindustrial era, 55, 59–63, 108 American Medical Association, 60–62 educational reform, 62–63 health insurance, 64–72 hospitals, development of, 63 medical profession, 60 organized medicine and, 61 scientific discoveries, 59, 60 396 Index specialists, overemphasis on, 60 urbanization effects on, 60 poverty, 47, 273, 277 PPO See preferred provider organization PPS See prospective payment system PQRS See Physician Quality Reporting System practice behaviors, legal risks influence, 18–19 precertification for treatment, 228, 233 predisposing characteristics, 271–278, 271e racial/ethnic minorities, 272–274 rural health, 277–278 women and children, 274–277 preferred provider organization (PPO) difference from HMO and POS plans, 230e Medicare Advantage and, 151 number of, 3, number of enrollees, overview, 233 reimbursement, 157, 226 preindustrial era, history of medicine in the U.S., 55–59 medical institutions, 58–59 medical practice, 56–57 medical training, 56–59 premium cost sharing, 140 premium, definition of, 140 prescription drug benefit (Part D), 70 prescription drug coverage (Part D), 151–152, 321 Prescription Drug User Fee Act (1992), 118e, 119 presidential leadership effect on health policy, 327–329 impact of, 327–329 Prevention and Public Health Fund, price rationing, 38 primary care, 86–87, 187–188 See also outpatient services access to, 170e accountability issues, 181 assessment of community health centers, 185–187 community-oriented, 179, 181 coordination role in health delivery, 179–180, 179f cost of care and, 183 defining, 177–178 disease management and, 181 domains of, 178–181, 178e effectiveness of, 181–185 emergency care use and, 182–183, 347 as essential care, 180 hospitalization rates and, 182–183 integrated, 180 medical-home strategy, 185 morbidity and, 183–184 mortality and, 184–185 overview, 176 as point of entry to health services, 178 reform, 20 primary care physicians, 85 ambulatory visits by, 87t decline in supply of, 89–90 future educational needs, 354 Primary Care Transition Fund, 20 primary, definition of, 136 private for-profit hospitals, 206 private health insurance, 141–145 Affordable Care Act, 145–147 emergence and rise of, 64 family plan, 141 group insurance, 143 high-deductible health plans, 144–145 individual plan, 144 managed care plans, 144, 225 self-insurance, 143 private nonprofit hospitals, 205–206 private sector approach, 234 government as subsidiary to, 320–321 process domain, quality of health care, 309 process improvement, developments in, 311–312 processes, health care system, 24–25, 24f proprietary hospitals See private for-profit hospitals PROs See peer review organizations prospective payment system (PPS), 158, 319 decline in average length of stay and, 201 prospective reimbursement, 157–158 ambulatory payment classifications and, 159 defining, 158 diagnosis-related groups and, 158–159, 198 prospective utilization review, 228, 233 provider-induced demand, 16, 138, 157 providers and professionals, health care allied health professionals, 99–101 chiropractors, 94t, 95 dentists, 91–92, 91t Index 397 doctoral-level health professionals, 93–95, 94t employment levels of doctoral-level, 94t health services administrators, 102–103 increasing demand for, 83 nonphysician practitioner, 97–99 nurses, 95–97 optometrists, 93–95 percentage of labor force, 81, 82t persons employed at health services sites, 82t pharmacists, 92–93, 93t podiatrists, 94, 94t psychologists, 94, 94t public health professionals, 101 specialization, effect on employment, 83 work settings for, 87, 87t psychiatric hospitals, 207 psychologists, 94, 94t PTs See physical therapists public health defining, 43 disasters, and bioterrorism, 345–346 professionals, 101 services, 175 social justice and, 38–40 system, 8–9, 43 Public Health Service Act of 1944, 121 public hospitals, 203–204 public insurance, 147–154 Affordable Care Act, 155 Children’s Health Insurance Program, 153–154 hospital insurance (Part A), 148–150 Medicaid, 152–153 Medicare, 147–148 Medicare Advantage (Part C), 150–151 prescription drug coverage (Part D), 151–152 supplementary medical insurance (Part B), 150 public policies, 318 public trust, 214 Q QHP See Quality Health Plan QIOs See quality improvement organizations quad-function model, 2f, quality, health care average in, 306–310 domains of, 308f Quality Health Plan (QHP), 310 quality improvement organizations (QIOs), 300 quality indicators, for managed care, 221–222 quality of care community health centers and, 185–186 criteria for, 123e impact on, 122–123 managed care and, 235 policy on, 335–336 quality of life, 33 indicators, 283 long-term care and, 252–253 technology and, 124 R racial/ethnic minorities, 272–274 access and, 272–274, 273e, 305 disparities, comparison across groups, 273e federal programs to reduce disparities, 275e mortality and, 273e, 274 radiological technicians, 100 radiopharmacists, 93 Rand Health Insurance Experiment, 141 rational drug design, 357 RBRVS See resource-based relative value scale R&D See research and development Reagan, Ronald, 300, 328 redistributive policies, 320 regenerative medicine, 357, 358 Regier, D A., 284 regional health care system, 239 registered nurses (RNs), 95, 193, 260 regulatory tool, health policy as, 319 rehabilitation, 260, 263 hospitals, 208 reimbursement, 156–160 Affordable Care Act, 160 ambulatory payment classifications (APCs), 159 bundled payments, 156 defining, 156 diagnosis-related groups and, 158–159 fee-for-service, 156 home health resource groups, 160 managed care, 157, 220 Medicaid, 10, 17 medical technology, 138 Medicare, 10, 17, 156–160, 299, 335 national health expenditures, 161–163 outpatient services, 171 package pricing, 156 per diem reimbursement rates, 157 398 Index preferred provider organization, 144, 226 prospective, 157–158, 198 resource-based relative value scale, 157 resource utilization groups, 159–160 retrospective, 157–158, 299 specialty maldistribution and, 90 reinsurance, 143 remote monitoring, 114 research and development (R&D), 107, 116e, 126, 296, 318 residency, 84 resource-based relative value scale (RBRVS), 157, 300 resource utilization group (RUG), 159–160 resources, system, 23 respiratory therapists, 260 respiratory therapy technicians, 100 respite care, 263 restorative care, 263 retirement facilities, 257–258 retrospective reimbursement, 157–158, 299 retrospective utilization review, 229 right to die, 335 rights of patient, 112 risk, 139 management, 312 RNs See registered nurses Roosevelt, Franklin, 67 Roosevelt, Theodore, 66 RUG See resource utilization group RUG-IV classifications, 159–160 rural communities, 277 rural health, 277–278 rural health centers, 175 Rural Health Clinics Act, 278 rural hospitals, 208–209 S SAEM See Society for Academic Emergency Medicine Safe Medical Devices Act of 1990, 118e, 121 safety net, 5, 7, 172, 175 safety of medical technology, 128 SARS See severe acute respiratory syndrome Second Act to Strengthen Long-Term Care, 20 secondary care, 86, 177, 180, 227 Section 701 of the Public Health Service Act, 99 Security tax revenues (Part A), 321 self-employment, 172 self-insurance, 143 senior centers, 255 severe acute respiratory syndrome (SARS), 345 shared responsibility payment, 146 Shared Savings Program, 237 Sheppard-Towner Act (1921), 305–306 sickness funds, 19 single-payer systems, 299, 349–350 skilled nursing care, 259 skilled nursing facilities (SNFs), 148–150, 259–260 certification, nursing homes, 262 small-area variations, 298 smoking and tobacco use, policy on, 334 SNFs See skilled nursing facilities social determinants of health, 44f, 45 Social Health Insurance, 21 social justice, 16–17, 38–40 market justice versus, 39t principle of, 39–40 U.S health care system and, 40–41 social points of intervention, 46–48 social relationships, holistic caregiving, 252 Social Security, 342 Social Security Act, 317 Social Security Amendments, 198, 299 social workers, 101, 213, 354 socialism, 36 socialized medicine, 67 Society for Academic Emergency Medicine (SAEM), 30–31 socioeconomic disparities, initiatives to eliminate, 281–283 socioeconomic status and health, 34, 45, 279, 305 special populations, subsystem for, 5–7 specialists ambulatory visits by, 87t certification of, 85 costs issues, 90 for dentists, 2012, 91t hospitalists, 85–86 maldistribution of, 89–90 oversupply of, 117 primary versus specialty care, 86–87 specialized care facilities, 260–261 specialty hospitals, 207 speech/language pathologists, 260, 263 speech therapy, 174 Index 399 speech–language pathologists, 101 Speech–Language–Hearing Association, 101 spirituality, health and, 176, 252 staff model HMO, 231 standardized practice protocols, for medical technology, 130 standards, certification, 10 state hospitals, 203, 207 state Medicaid programs, federally mandated services for, 154t state-of-the-art technology, 117 State Units on Aging, 253 stop-loss provision, 141 structure domain, quality of health care, 309 subacute care, 201 facilities, 260 subacute condition, 33 subsystems of health care delivery, 3–9 integrated delivery, long-term care delivery, 7–8 managed care, 2, 2f, 3–4 military, 4–5 public health system, 8–9 special populations, 5–7 supplementary medical insurance (Part B), 150 Supplementary Medical Insurance trust fund, 351 supply-side rationing, 40, 108, 115, 138, 234, 299 supply-side regulation, 300–301 surgicenters, 173 system foundations, 23, 24f system outcomes, 24f, 25 system outlook, 24f, 25 system processes, 24–25, 24f system resources, 23, 24f systems framework, 23–25, 24f T taxation benefits for nonprofit organizations, 205–206 teaching hospitals, 62, 158, 177, 209 teamlet model, 353 technicians, 100, 212 technological imperative, 116 technologists, 100–101 technology diffusion, 114 government role in, 117–122 technology, medical, 110e, 296 acute care focus of, 10–11 Affordable Care Act and, 121–122 assessment of, 127–129 benefits of assessment, 129–130 bioethics and, 127 changes triggered by, 108 cost containment and, 130 cost-effectiveness of, 114, 127–129 cost increases associated with, 125e cost-saving, 125e, 326 costs and, 11, 60, 63, 107, 114 criteria for quality of care, 123e defining, 109 diffusion and utilization of, 114–117 e-health, 73 effects of, 122 efficacy of, 127, 128 examples of, 110e future of, 356–357 geographical access and, 126 global medical practice, impact on, 126–127 government role in technology diffusion, 117–122 health care costs, impact on, 125e hospitals, impact of, 126 impact of, 122–127 information technology, 110–114 mechanisms to control growth of, 116e medical training and practice, 108 outpatient services and, 171 outsourcing of medical services, 74 policy, manufacturers influence on, 325–326 postindustrial interest in, 60 quality of life and, 124 research on, 122 safety of, 128 specialty maldistribution and, 90 standardized practice protocols and, 130 structure and processes of health care delivery, impact on, 126 telemedicine, 73, 111, 114 value and, 129–130 tele-ICU, 114 telemedicine, 73, 111, 114 telephone triage, 173–174 Tenet Health System, 206 10-Year Plan to Strengthen Health Care, 19–20 tertiary care, 86, 90, 177, 180, 209 thalidomide, 119 therapists, 100–101 400 Index third-party payers, 156, 296 Title 18 of the Social Security Act, 69 Title 19 of the Social Security Act, 70, 152 Title III of Older Americans Act, 253 Title XX Social Services Block Grants, 253 top-level health services administrators, 102 total health care expenditures, effect of financing on, 138 transplantation, 209, 357 TriCare, 4–5 Truman, Harry, 67, 328 U UCR See usual, customary, and reasonable underutilization, 229, 311 underwriting, insurance, 139 uninsured persons access issues for, 11, 18 Affordable Care Act (ACA) and, 155, 279 numbers in U.S., 10 United Kingdom health care system in, 21–22, 22t hospitalists in, 86 policy study on, 338 United States health care spending versus other developed countries, 294t–295t health care system versus other developed countries, 21, 22t policy study on, 338 universal access, 25, 327, 349 universal coverage, 348–349 universal health care, 108 urgent care centers, 173 U.S Department of Defense medical care system, U.S health care system, 112 U.S health care today, 76–77 U.S Office of Minority Health, 275e U.S Supreme Court, 66, 344 usual, customary, and reasonable (UCR), 156 usual source of care, 274 utilization controls on, 171, 301 hospitals and, 200–202, 202t overutilization, 229 underutilization, 229 utilization review, 227 concurrent, 228 prospective, 228 retrospective, 229 V vaccines, 357 value and beliefs, 36, 37, 68, 116 concept of, 129–130 value-based payment, 160 vertical integration, 240–241 Veterans Administration (VA) health care system, 5, 203 Veterans Health Administration, 335 Veterans Integrated Service Networks (VISNs), virtual integration, 240 virtual organizations, 240 virtual visits, 111 VISNs See Veterans Integrated Service Networks voluntary health insurance, 64 voluntary hospitals See private nonprofit hospitals vulnerability, definition of, 270 vulnerable populations, 269–286 children, 274–277 chronic illness/disability, 284–285 enabling characteristics, 271e, 279–281 framework for studying, 270–271, 270f health care delivery subsystems for, 5–7 HIV/AIDS, persons with, 285–286 homeless persons, 279–281 mental health issues of, 283–284 need characteristics, 271e, 283–286 predisposing characteristics, 271–278, 271e racial/ethnic minorities, 272–274, 273e rural health, 277–278 women and children, 274–277 in rural area, 278 socioeconomic disparities, 281–283 uninsured, 279, 280f women, 283 W walk-in clinics, 173 wellness promotion, 98 Wennberg, John, 298 Index 401 West Nile virus, 345–346 WHO See World Health Organization Wilson, Woodrow, 67 women health coverage for pregnant, 152, 154, 322, 327 as vulnerable populations, 274–277, 283 women’s health centers, 196 workers’ compensation, 40–41, 64 World Health Organization (WHO), 45–46, 355 definition of health, 30 definition of health care system, 31–32 definition of primary care, 177 World War I, 66, 67, 95 World War II, 66 X xenotransplantation, 357 Y young adults, in long-term care, 245 ... Statistics, 2007; Urban Institute, 2011; U. S Bureau of the Census, 1998; U. S Census Bureau, 2007) SUBSYSTEMS OF U. S HEALTH CARE DELIVERY In the United States, multiple subsystems of health care delivery... Characteristics of U. S Health Care Delivery 1 Introduction 1 Subsystems of U. S Health Care Delivery Characteristics of the U. S Health Care System Health Care Systems of Other Developed Countries ... are system inputs (resources), system structure, system processes, and system outputs (outcomes) In addition, system outlook (future directions) is a necessary element of a dynamic system This