Wiley Pathways Introduction to U.S. Health Care: The Structure of Management and Financing of the U.S. Health Care System

Part I: Foundations 1

1 The U.S Health Care System 1

Introduction 2

1.1 Gauging the Size of the Health Care Industry 2

Self-Check 4

1.2 Balancing Public and Private Health: Health Care Organizations 4

1.2.1 Protecting Populations: Public Health Care Organizations 5

1.2.2 Serving Individuals: Private Health Care Organizations 5

Self-Check 8

1.3 Identifying Health Systems 9

1.3.1 Types of Health Systems 9

1.3.2 Forming Health Systems 10

Self-Check 11

1.4 Classifying Health Care Industry Sectors 11

1.4.1 Financing 11

1.4.2 Institutional Providers 12

1.4.3 Individual Providers 12

1.4.4 Public Health Agencies 13

1.4.5 Enablers 13

1.4.6 Suppliers 13

1.4.7 Regulators 13

Self-Check 14

1.5 Defining Health and Disease 15

1.5.1 Causes of Disease 15

1.5.2 Analyzing U.S Health and Disease Status 16

Self-Check 18

1.6 Accessing Health Services in the United States 19

1.6.1 Triggers to Utilizing the Health Care System 19

1.6.2 Factors Affecting Utilization 20

1.6.3 The Role of Health Services Administration Research 21

Self-Check 23

Summary 23

Key Terms 23

Summary Questions 25

Review Questions 27

Applying This Chapter 28

You Try It 29

2 Boards and Governance 30

Introduction 31

2.1 Understanding the Role of Governing Boards 31

2.1.1 Determining Mission, Vision, and Values 32

2.1.2 Ensuring Management Performance 33

2.1.3 Ensuring Quality of Care 34

2.1.4 Ensuring Financial Health 34

Self-Check 35

2.2 Board Composition, Structure, and Infrastructure 35

2.2.1 Health Systems 36

2.2.2 Hospitals 37

Self-Check 38

2.3 Challenges Facing Boards 39

2.3.1 Liability of Board Members 39

2.3.2 Reporting and Disclosure of Accounting Information 40

2.3.3 Conflict of Interest 40

2.3.4 Board Performance 41

Self-Check 41

Summary 41

Key Terms 41

Summary Questions 44

Review Questions 44

Applying This Chapter 45

You Try It 46

Part II: Health Care Organization and Financing 47

3 Health Care Provision 47

Introduction 48

3.1 Health Provision at a Glance: Specialty-Care versus Primary-Care 48

3.1.1 Primary-Care Model 49

3.1.2 Specialty-Care Model 49

Self-Check 50

3.2 Primary Care Reforms in the United States 50

3.2.1 Benefits of the Primary Care Model 51

3.2.2 Predicting Primary Care’s Future in the United States 52

Self-Check 52

3.3 Performance of the Primary Care Model in the United States 52

3.3.1 Accessibility 53

3.3.2 Continuity 53

3.3.3 Comprehensiveness 54

3.3.4 Coordination 54

3.3.5 Accountability to the Community 54

3.3.6 Its Effect on Primary Care Providers 55

Self-Check 55

3.4 Primary Care Innovations 55

3.4.1 The Primary Care Team 55

3.4.2 Chronic Care Model and Collaborative Care 56

Self-Check 57

3.5 Identifying the PCP 57

3.5.1 Permeable Boundaries Between Generalist, Specialist, and Other Functions 58

3.5.2 Specialists Providing Primary Care 58

3.5.3 Generalists Providing Secondary Care 58

3.5.4 Hospitalists Dedicated to General Inpatient Care 59

3.5.5 Nonphysician Primary Care Clinicians 60

Self-Check 60

3.6 PCPs and the Populations They Serve 60

3.6.1 Health Profession Shortage Areas (HPSAs) 61

3.6.2 Federal and State Strategies 62

Self-Check 63

Summary 63

Key Terms 64

Summary Questions 66

Review Questions 68

Applying This Chapter 72

You Try It 73

4 Financing the U.S Health Care System 74

Introduction 75

4.1 Changing Economic Dynamics 75

4.1.1 Increasing Expenditures 76

4.1.2 Reasons for the Increase 77

4.1.3 Affecting How Health Care is Financed 79

Self-Check 80

4.2 Flow of Funds through the System 80

4.2.1 Where the Money Comes From 80

4.2.2 Where the Money Goes 82

4.2.3 How It Gets There 82

Self-Check 84

4.3 Examining Who Has Health Insurance 84

Self-Check 87

4.4 Categorizing Health Insurance Plans 87

4.4.1 Indemnity plan 88

4.4.2 Service Benefit Plan 89

4.4.3 Managed Care Plan 90

Self-Check 91

4.5 Private Insurance Coverage: Voluntary Health Insurance (VHI) 92

4.5.1 Types of VHI Plans 92

4.5.2 Coverage Variations in VHI Plans 93

Self-Check 94

4.6 Government Insurance Programs: Medicare and Medicaid 94

4.6.1 Social Health Insurance: Medicare 94

4.6.2 Welfare Insurance: Medicaid 96

Self-Check 98

4.7 Health Maintenance Organizations (HMOs) 99

4.7.1 HMO Growth 99

4.7.2 HMO Models 99

Self-Check 101

Summary 101

Key Terms 102

Summary Questions 104

Review Questions 107

Applying This Chapter 108

You Try It 109

Part III: Health Care Resources 110

5 The Health Care Workforce 110

Introduction 111

5.1 Sizing Up the Workforce 111

Self-Check 114

5.2 Understanding the Role of the Physician 114

5.2.1 Counting All Doctors 114

5.2.2 Specialists 116

5.2.3 General practitioners 117

5.2.4 Hospitalists 118

Self-Check 118

5.3 Training Doctors 118

5.3.1 Medical School 119

5.3.2 Residency and Fellowship 119

Self-Check 121

5.4 Nurses 121

5.4.1 Registered Nurses (RNs) 121

5.4.2 Training Requirements 123

5.4.3 Where the Nurses are 123

5.4.4 Other Nursing Personnel: LPNs and LVNs 124

Self-Check 125

5.5 Other Independent Health Professionals 125

5.5.1 Dentists 126

5.5.2 Chiropractors 126

5.5.3 Optometrists 127

5.5.4 Podiatrists 127

5.5.5 Pharmacists 128

Self-Check 129

5.6 Working in Concert with Physicians 129

5.6.1 Physical Therapists 129

5.6.2 Physician Assistants 130

Self-Check 131

Summary 131

Key Terms 132

Summary Questions 135

Review Questions 137

Applying This Chapter 139

You Try It 140

6 Research and Technology 141

Introduction 142

6.1 Understanding Medical Research 142

6.1.1 Advances in Knowledge 143

6.1.2 Advances in Diagnostic Techniques 145

6.1.3 Advances in Treatment Options and

Therapeutic Interventions 146

6.1.4 Advances in Pharmaceuticals 147

6.1.5 Advances in Information and Communication Technologies 147

Self-Check 149

6.2 Research Facilities 149

6.2.1 Public Research Facilities: National Institutes of Health (NIHs) 149

6.2.2 Academic Health Centers 151

6.2.3 Private Research Facilities 152

6.2.4 Core Facilities 152

Self-Check 153

6.3 Funding Research: Knowing Where the Money Comes From 153

6.3.1 Public Funds 153

6.3.2 Private Donors/Benefactors 154

Self-Check 155

6.4 Assessment and Challenges of Continuing Medical Advancement 155

6.4.1 The Shift from Public to Private Research Endeavors 155

6.4.2 Issues Regarding Research in General Internal Medicine 155

6.4.3 The Impact on Academic Health Centers 156

6.4.4 Cost To Health Care 156

Self-Check 157

Summary 158

Key Terms 158

Summary Questions 159

Review Questions 161

Applying This Chapter 162

You Try It 164

Part IV: The Health Care Delivery System 165

7 Hospitals in the U.S. 165

Introduction 166

7.1 The Evolution of Hospitals in the U.S 166

7.1.1 Forming Hospitals: the Refuge Stage 166

7.1.2 Hospitals As the Center of Health Care: Physician Workshop Stage 168

7.1.3 Becoming More Business Oriented: The Business Stage 169

7.1.4 Managing Complex Systems: The System Stage 169

Self-Check 170

7.2 Components and Cost of American Hospitals 170

7.2.1 Hospital Components 170

7.2.2 Hospital Costs 171

Self-Check 172

7.3 Classifying Hospitals 173

7.3.1 Length of Stay: Short-and Long-Term Hospitals 174

7.3.2 Type of Service: General and Specialty Hospitals 174

7.3.3 Ownership: Nonprofit, Proprietary, and Governmental 175

Self-Check 176

7.4 Care and Competition in the Twenty-First Century 177

7.4.1 Hospital Care 177

7.4.2 Competition in Health Care 178

Self-Check 179

Summary 179

Key Terms 180

Summary Questions 182

Review Questions 183

Applying This Chapter 184

You Try It 185

8 Ambulatory Care 186

Introduction 187

8.1 Understanding Ambulatory Care 187

8.1.1 The Growing Reliance on Ambulatory Care 188

8.1.2 Accessing Ambulatory Care 189

8.1.3 Paying For Ambulatory Care 189

8.1.4 Ambulatory Care Accreditation 190

Self-Check 191

8.2 Ambulatory Care Settings and Providers 191

8.2.1 Physician Offices: Solo and Group Practices 192

8.2.2 Emergency Rooms and Hospital Outpatient Departments 193

8.2.3 Urgent Care Facilities 194

8.2.4 Same-Day Surgery Centers 194

8.2.5 Community Health Centers and Clinics 195

8.2.6 Student Health Centres or Clinics 196

8.2.7 Occupational Health Programs 197

Self-Check 197

8.3 Home Health and Visiting Nurse Agencies 197

Self-Check 199

Summary 199

Key Terms 200

Summary Questions 201

Review Questions 202

Applying This Chapter 204

You Try It 205

9 Long-Term Care 206

Introduction 207

9.1 Understanding Long-Term Care 207

9.1.1 Typical Long-Term Care Services 207

9.1.2 People Who Need Long-Term Care 208

Self-Check 209

9.2 Personal Care Facilities 209

9.2.1 Assisted Living Facilities 210

9.2.2 Continuing Care Retirement Communities (CCRCs) 210

9.2.3 Congregate Care Facilities 211

9.2.4 Nursing Homes 211

9.2.5 Alzheimer’s /Dementia Facilities 213

Self-Check 214

9.3 Community-Based and Home Health Care 214

9.3.1 Receiving Care at Home 215

9.3.2 Taking Advantage of Community-Based Care 216

Self-Check 218

9.4 Rehabilitation Centers 218

Self-Check 219

9.5 Hospice Care 219

9.5.1 Hospice Service Providers 219

9.5.2 Hospice Services 220

9.5.3 Accessing Hospice Care 221

9.5.4 Financing Hospice Care 222

Self-Check 222

Summary 222

Key Terms 222

Summary Questions 225

Review Questions 226

Applying This Chapter 227

You Try It 229

10 Caring For Special Populations 230

Introduction 231

10.1 Caring For Mentally Ill Patients 231

10.1.1 Providing Mental Health Services 231

10.1.2 Paying For Mental Health Services 234

10.1.3 Challenges To Accessing And Providing Care For Mentally Ill Patients 235

10.1.4 Legal Issues Regarding Health Care for Mentally Ill Patients 237

Self-Check 239

10.2 Homeless Patients 239

10.2.1 Health Issues in the Homeless Population 240

10.2.2 Challenges in Providing Health Care to Homeless 240

Self-Check 241

10.3 Veterans 241

10.3.1 Health Issues For Veterans 241

10.3.2 Challenges in Providing Health Care to Veterans 242

Self-Check 243

10.4 Immigrants 243

10.4.1 Challenges in Providing Health Care to Immigrants 243

10.4.2 Legal Issues Regarding Health Care for Immigrants 244

Self-Check 245

10.5 Caring For Other Special Populations 245

10.5.1 People With AIDS and HIV 245

10.5.2 Victims of Violence 246

Self-Check 246

Summary 247

Key Terms 247

Summary Questions 249

Review Questions 251

Applying This Chapter 251

You Try It 253

11 Caring For Uninsured Patients 254

Introduction 255

11.1 Identifying Uninsured Patients 255

Self-Check 257

11.2 Accessing Health Care When Uninsured 257

11.2.1 Community Health Centers and Clinics 257

11.2.2 Urgent Care Facilities 257

11.2.3 Emergency Rooms 258

Self-Check 260

11.3 Challenges in Providing Health Care to Uninsured Patients 260

11.3.1 Health-Related Challenges 260

11.3.2 Financial-Related Challenges 261

Self-Check 263

11.4 Legal Issues and Uninsured Patients 263

Self-Check 264

Summary 264

Key Terms 264

Summary Questions 266

Review Questions 267

Applying This Chapter 267

You Try It 268

12 Managed Care 269

Introduction 270

12.1 Understanding Managed Care 270

12.1.1 Controlling Costs 270

12.1.2 Ensuring Quality 271

12.1.3 Understanding How Managed Care Works 272

Self-Check 272

12.2 Types of Managed Care Organizations 273

12.2.1 Health Maintenance Organizations (HMOs) 273

12.2.2 Preferred Provider Organizations (PPOs) 275

12.2.3 Point-Of-Service (POS) Plans 275

Self-Check 276

12.3 Assessing the Performance of Managed Care 276

12.3.1 Impact on Quality and Cost 276

12.3.2 Impact on Physicians and Health Care Providers 277

12.3.3 The Future of Managed Care 278

Self-Check 278

Summary 279

Key Terms 279

Summary Questions 281

Review Questions 282

Applying This Chapter 284

You Try It 285

Part V: Challenges Of US Health Care 286

13 Promoting Health And Preventing Disease 286

Introduction 287

13.1 Growing Complexity of the U.S Health Care System 287

13.1.1 The Effect on Governing Boards 288

13.1.2 The Challenge to Health Systems 289

Self-Check 290

13.2 Financing Health Care 290

13.2.1 Government Initiatives 291

13.2.2 Evolving Health Insurance and Health Plans 292

13.2.3 Funding Medicare 293

Self-Check 294

13.3 Aging Population 294

13.3.1 Demand and Cost for Short-Term Care 294

13.3.2 Demand For Long-Term Care 295

Self-Check 296

13.4 Challenges for Primary Care 296

13.4.1 The Cult of Specialization 296

13.4.2 Too Few Generalists; Too Many Specialists 298

13.4.3 The Unexpected Impact of Managed Care 298

13.4.4 The Lack of Government Direction Regarding Primary Care Physicians 299

13.4.5 Changing Medical Models 300

Self-Check 302

13.5 Examining The Underserved: Rural and Inner-City Areas 302

13.5.1 Lack of Racial and Ethnically Diverse Doctors 302

13.5.2 Declining Numbers of General Practitioners 303

13.5.3 Location of Practices 303

13.5.4 Lack of Coordinated Effort to Address Shortage 304

13.5.5 Role of Gender on Choice of Practice Location 305

Self-Check 305

13.6 Fixing the Problem of the Underserved 305

13.6.1 Bolstering Ethnically Diverse Workforce 305

13.6.2 Changing Medical Education System 306

13.6.3 Changing Reimbursement Strategies of Medicare and Medicaid 307

13.6.4 Changes in Existing Direct Federal and State Programs 307

13.6.5 Relying on the Impact of Managed Care 307

Self-Check 308

13.7 Other Challenges 309

13.7.1 Advancing Technology 309

13.7.2 Shortage of Nurses 309

13.7.3 Evolving Public Health Threats 310

13.7.4 Declining Financial Health of Hospitals 310

Self-Check 311

Summary 311

Key Terms 311

Summary Questions 313

Review Questions 315

Applying This Chapter 316

You Try It 318

14 Public Health Policy 319

Introduction 320

14.1 Public Health Services 320

14.1.1 Federal Health Agencies 322

14.1.2 State Health Agencies 323

14.1.3 Local Health Agencies 325

14.1.4 Private Initiatives in Public Health Policy 327

Self-Check 328

14.2 Federal and State Health Laws 328

14.2.1 Federal Statutes and Regulations 328

14.2.2 State Statutes and Regulations 329

Self-Check 330

14.3 Assessing U.S Health Policy 330

Self-Check 331

14.4 Comparing U.S Health Care to Health Care in Other Countries 332

14.4.1 Health Indicators 332

14.4.2 Characteristics of the Health System 332

14.4.3 Primary Care of Specialty Care-Based System 333

Self-Check 334

Summary 334

Key Terms 335

Summary Questions 336

Review Questions 337

Applying This Chapter 338

You Try It 340

Endnotes 341

Glossary 343

Index 359