Wiley Pathways Introduction to U.S. Health Care

Dennis D. Pointer is president of Dennis D. Pointer & Associates and the author of numerous books including Board Work (Jossey-Bass, 1999), winner of the James A. Hamilton Book of the Year Award from the American College of Healthcare Executives. Dr. Pointer is the Austin Ross Professor in the Department of Health Services at the University of Washington School of Public Health and Community Medicine.

• Part I: Foundations 11 The U.S Health Care System 1Introduction 21.1 Gauging the Size of the Health Care Industry 2Self-Check 41.2 Balancing Public and Private Health: Health Care Organizations 41.2.1 Protecting Populations: Public Health Care Organizations 51.2.2 Serving Individuals: Private Health Care Organizations 5Self-Check 81.3 Identifying Health Systems 91.3.1 Types of Health Systems 91.3.2 Forming Health Systems 10Self-Check 111.4 Classifying Health Care Industry Sectors 111.4.1 Financing 111.4.2 Institutional Providers 121.4.3 Individual Providers 121.4.4 Public Health Agencies 131.4.5 Enablers 131.4.6 Suppliers 131.4.7 Regulators 13Self-Check 141.5 Defining Health and Disease 151.5.1 Causes of Disease 151.5.2 Analyzing U.S Health and Disease Status 16Self-Check 181.6 Accessing Health Services in the United States 191.6.1 Triggers to Utilizing the Health Care System 191.6.2 Factors Affecting Utilization 201.6.3 The Role of Health Services Administration Research 21Self-Check 23Summary 23Key Terms 23Summary Questions 25Review Questions 27Applying This Chapter 28You Try It 292 Boards and Governance 30Introduction 312.1 Understanding the Role of Governing Boards 312.1.1 Determining Mission, Vision, and Values 322.1.2 Ensuring Management Performance 332.1.3 Ensuring Quality of Care 342.1.4 Ensuring Financial Health 34Self-Check 352.2 Board Composition, Structure, and Infrastructure 352.2.1 Health Systems 362.2.2 Hospitals 37Self-Check 382.3 Challenges Facing Boards 392.3.1 Liability of Board Members 392.3.2 Reporting and Disclosure of Accounting Information 402.3.3 Conflict of Interest 402.3.4 Board Performance 41Self-Check 41Summary 41Key Terms 41Summary Questions 44Review Questions 44Applying This Chapter 45You Try It 46Part II: Health Care Organization and Financing 473 Health Care Provision 47Introduction 483.1 Health Provision at a Glance: Specialty-Care versus Primary-Care 483.1.1 Primary-Care Model 493.1.2 Specialty-Care Model 49Self-Check 503.2 Primary Care Reforms in the United States 503.2.1 Benefits of the Primary Care Model 513.2.2 Predicting Primary Care’s Future in the United States 52Self-Check 523.3 Performance of the Primary Care Model in the United States 523.3.1 Accessibility 533.3.2 Continuity 533.3.3 Comprehensiveness 543.3.4 Coordination 543.3.5 Accountability to the Community 543.3.6 Its Effect on Primary Care Providers 55Self-Check 553.4 Primary Care Innovations 553.4.1 The Primary Care Team 553.4.2 Chronic Care Model and Collaborative Care 56Self-Check 573.5 Identifying the PCP 573.5.1 Permeable Boundaries Between Generalist, Specialist, and Other Functions 583.5.2 Specialists Providing Primary Care 583.5.3 Generalists Providing Secondary Care 583.5.4 Hospitalists Dedicated to General Inpatient Care 593.5.5 Nonphysician Primary Care Clinicians 60Self-Check 603.6 PCPs and the Populations They Serve 603.6.1 Health Profession Shortage Areas (HPSAs) 613.6.2 Federal and State Strategies 62Self-Check 63Summary 63Key Terms 64Summary Questions 66Review Questions 68Applying This Chapter 72You Try It 734 Financing the U.S Health Care System 74Introduction 754.1 Changing Economic Dynamics 754.1.1 Increasing Expenditures 764.1.2 Reasons for the Increase 774.1.3 Affecting How Health Care is Financed 79Self-Check 804.2 Flow of Funds through the System 804.2.1 Where the Money Comes From 804.2.2 Where the Money Goes 824.2.3 How It Gets There 82Self-Check 844.3 Examining Who Has Health Insurance 84Self-Check 874.4 Categorizing Health Insurance Plans 874.4.1 Indemnity plan 884.4.2 Service Benefit Plan 894.4.3 Managed Care Plan 90Self-Check 914.5 Private Insurance Coverage: Voluntary Health Insurance (VHI) 924.5.1 Types of VHI Plans 924.5.2 Coverage Variations in VHI Plans 93Self-Check 944.6 Government Insurance Programs: Medicare and Medicaid 944.6.1 Social Health Insurance: Medicare 944.6.2 Welfare Insurance: Medicaid 96Self-Check 984.7 Health Maintenance Organizations (HMOs) 994.7.1 HMO Growth 994.7.2 HMO Models 99Self-Check 101Summary 101Key Terms 102Summary Questions 104Review Questions 107Applying This Chapter 108You Try It 109Part III: Health Care Resources 1105 The Health Care Workforce 110Introduction 1115.1 Sizing Up the Workforce 111Self-Check 1145.2 Understanding the Role of the Physician 1145.2.1 Counting All Doctors 1145.2.2 Specialists 1165.2.3 General practitioners 1175.2.4 Hospitalists 118Self-Check 1185.3 Training Doctors 1185.3.1 Medical School 1195.3.2 Residency and Fellowship 119Self-Check 1215.4 Nurses 1215.4.1 Registered Nurses (RNs) 1215.4.2 Training Requirements 1235.4.3 Where the Nurses are 1235.4.4 Other Nursing Personnel: LPNs and LVNs 124Self-Check 1255.5 Other Independent Health Professionals 1255.5.1 Dentists 1265.5.2 Chiropractors 1265.5.3 Optometrists 1275.5.4 Podiatrists 1275.5.5 Pharmacists 128Self-Check 1295.6 Working in Concert with Physicians 1295.6.1 Physical Therapists 1295.6.2 Physician Assistants 130Self-Check 131Summary 131Key Terms 132Summary Questions 135Review Questions 137Applying This Chapter 139You Try It 1406 Research and Technology 141Introduction 1426.1 Understanding Medical Research 1426.1.1 Advances in Knowledge 1436.1.2 Advances in Diagnostic Techniques 1456.1.3 Advances in Treatment Options andTherapeutic Interventions 1466.1.4 Advances in Pharmaceuticals 1476.1.5 Advances in Information and Communication Technologies 147Self-Check 1496.2 Research Facilities 1496.2.1 Public Research Facilities: National Institutes of Health (NIHs) 1496.2.2 Academic Health Centers 1516.2.3 Private Research Facilities 1526.2.4 Core Facilities 152Self-Check 1536.3 Funding Research: Knowing Where the Money Comes From 1536.3.1 Public Funds 1536.3.2 Private Donors/Benefactors 154Self-Check 1556.4 Assessment and Challenges of Continuing Medical Advancement 1556.4.1 The Shift from Public to Private Research Endeavors 1556.4.2 Issues Regarding Research in General Internal Medicine 1556.4.3 The Impact on Academic Health Centers 1566.4.4 Cost To Health Care 156Self-Check 157Summary 158Key Terms 158Summary Questions 159Review Questions 161Applying This Chapter 162You Try It 164Part IV: The Health Care Delivery System 1657 Hospitals in the U.S. 165Introduction 1667.1 The Evolution of Hospitals in the U.S 1667.1.1 Forming Hospitals: the Refuge Stage 1667.1.2 Hospitals As the Center of Health Care: Physician Workshop Stage 1687.1.3 Becoming More Business Oriented: The Business Stage 1697.1.4 Managing Complex Systems: The System Stage 169Self-Check 1707.2 Components and Cost of American Hospitals 1707.2.1 Hospital Components 1707.2.2 Hospital Costs 171Self-Check 1727.3 Classifying Hospitals 1737.3.1 Length of Stay: Short-and Long-Term Hospitals 1747.3.2 Type of Service: General and Specialty Hospitals 1747.3.3 Ownership: Nonprofit, Proprietary, and Governmental 175Self-Check 1767.4 Care and Competition in the Twenty-First Century 1777.4.1 Hospital Care 1777.4.2 Competition in Health Care 178Self-Check 179Summary 179Key Terms 180Summary Questions 182Review Questions 183Applying This Chapter 184You Try It 1858 Ambulatory Care 186Introduction 1878.1 Understanding Ambulatory Care 1878.1.1 The Growing Reliance on Ambulatory Care 1888.1.2 Accessing Ambulatory Care 1898.1.3 Paying For Ambulatory Care 1898.1.4 Ambulatory Care Accreditation 190Self-Check 1918.2 Ambulatory Care Settings and Providers 1918.2.1 Physician Offices: Solo and Group Practices 1928.2.2 Emergency Rooms and Hospital Outpatient Departments 1938.2.3 Urgent Care Facilities 1948.2.4 Same-Day Surgery Centers 1948.2.5 Community Health Centers and Clinics 1958.2.6 Student Health Centres or Clinics 1968.2.7 Occupational Health Programs 197Self-Check 1978.3 Home Health and Visiting Nurse Agencies 197Self-Check 199Summary 199Key Terms 200Summary Questions 201Review Questions 202Applying This Chapter 204You Try It 2059 Long-Term Care 206Introduction 2079.1 Understanding Long-Term Care 2079.1.1 Typical Long-Term Care Services 2079.1.2 People Who Need Long-Term Care 208Self-Check 2099.2 Personal Care Facilities 2099.2.1 Assisted Living Facilities 2109.2.2 Continuing Care Retirement Communities (CCRCs) 2109.2.3 Congregate Care Facilities 2119.2.4 Nursing Homes 2119.2.5 Alzheimer’s /Dementia Facilities 213Self-Check 2149.3 Community-Based and Home Health Care 2149.3.1 Receiving Care at Home 2159.3.2 Taking Advantage of Community-Based Care 216Self-Check 2189.4 Rehabilitation Centers 218Self-Check 2199.5 Hospice Care 2199.5.1 Hospice Service Providers 2199.5.2 Hospice Services 2209.5.3 Accessing Hospice Care 2219.5.4 Financing Hospice Care 222Self-Check 222Summary 222Key Terms 222Summary Questions 225Review Questions 226Applying This Chapter 227You Try It 22910 Caring For Special Populations 230Introduction 23110.1 Caring For Mentally Ill Patients 23110.1.1 Providing Mental Health Services 23110.1.2 Paying For Mental Health Services 23410.1.3 Challenges To Accessing And Providing Care For Mentally Ill Patients 23510.1.4 Legal Issues Regarding Health Care for Mentally Ill Patients 237Self-Check 23910.2 Homeless Patients 23910.2.1 Health Issues in the Homeless Population 24010.2.2 Challenges in Providing Health Care to Homeless 240Self-Check 24110.3 Veterans 24110.3.1 Health Issues For Veterans 24110.3.2 Challenges in Providing Health Care to Veterans 242Self-Check 24310.4 Immigrants 24310.4.1 Challenges in Providing Health Care to Immigrants 24310.4.2 Legal Issues Regarding Health Care for Immigrants 244Self-Check 24510.5 Caring For Other Special Populations 24510.5.1 People With AIDS and HIV 24510.5.2 Victims of Violence 246Self-Check 246Summary 247Key Terms 247Summary Questions 249Review Questions 251Applying This Chapter 251You Try It 25311 Caring For Uninsured Patients 254Introduction 25511.1 Identifying Uninsured Patients 255Self-Check 25711.2 Accessing Health Care When Uninsured 25711.2.1 Community Health Centers and Clinics 25711.2.2 Urgent Care Facilities 25711.2.3 Emergency Rooms 258Self-Check 26011.3 Challenges in Providing Health Care to Uninsured Patients 26011.3.1 Health-Related Challenges 26011.3.2 Financial-Related Challenges 261Self-Check 26311.4 Legal Issues and Uninsured Patients 263Self-Check 264Summary 264Key Terms 264Summary Questions 266Review Questions 267Applying This Chapter 267You Try It 26812 Managed Care 269Introduction 27012.1 Understanding Managed Care 27012.1.1 Controlling Costs 27012.1.2 Ensuring Quality 27112.1.3 Understanding How Managed Care Works 272Self-Check 27212.2 Types of Managed Care Organizations 27312.2.1 Health Maintenance Organizations (HMOs) 27312.2.2 Preferred Provider Organizations (PPOs) 27512.2.3 Point-Of-Service (POS) Plans 275Self-Check 27612.3 Assessing the Performance of Managed Care 27612.3.1 Impact on Quality and Cost 27612.3.2 Impact on Physicians and Health Care Providers 27712.3.3 The Future of Managed Care 278Self-Check 278Summary 279Key Terms 279Summary Questions 281Review Questions 282Applying This Chapter 284You Try It 285Part V: Challenges Of US Health Care 28613 Promoting Health And Preventing Disease 286Introduction 28713.1 Growing Complexity of the U.S Health Care System 28713.1.1 The Effect on Governing Boards 28813.1.2 The Challenge to Health Systems 289Self-Check 29013.2 Financing Health Care 29013.2.1 Government Initiatives 29113.2.2 Evolving Health Insurance and Health Plans 29213.2.3 Funding Medicare 293Self-Check 29413.3 Aging Population 29413.3.1 Demand and Cost for Short-Term Care 29413.3.2 Demand For Long-Term Care 295Self-Check 29613.4 Challenges for Primary Care 29613.4.1 The Cult of Specialization 29613.4.2 Too Few Generalists; Too Many Specialists 29813.4.3 The Unexpected Impact of Managed Care 29813.4.4 The Lack of Government Direction Regarding Primary Care Physicians 29913.4.5 Changing Medical Models 300Self-Check 30213.5 Examining The Underserved: Rural and Inner-City Areas 30213.5.1 Lack of Racial and Ethnically Diverse Doctors 30213.5.2 Declining Numbers of General Practitioners 30313.5.3 Location of Practices 30313.5.4 Lack of Coordinated Effort to Address Shortage 30413.5.5 Role of Gender on Choice of Practice Location 305Self-Check 30513.6 Fixing the Problem of the Underserved 30513.6.1 Bolstering Ethnically Diverse Workforce 30513.6.2 Changing Medical Education System 30613.6.3 Changing Reimbursement Strategies of Medicare and Medicaid 30713.6.4 Changes in Existing Direct Federal and State Programs 30713.6.5 Relying on the Impact of Managed Care 307Self-Check 30813.7 Other Challenges 30913.7.1 Advancing Technology 30913.7.2 Shortage of Nurses 30913.7.3 Evolving Public Health Threats 31013.7.4 Declining Financial Health of Hospitals 310Self-Check 311Summary 311Key Terms 311Summary Questions 313Review Questions 315Applying This Chapter 316You Try It 31814 Public Health Policy 319Introduction 32014.1 Public Health Services 32014.1.1 Federal Health Agencies 32214.1.2 State Health Agencies 32314.1.3 Local Health Agencies 32514.1.4 Private Initiatives in Public Health Policy 327Self-Check 32814.2 Federal and State Health Laws 32814.2.1 Federal Statutes and Regulations 32814.2.2 State Statutes and Regulations 329Self-Check 33014.3 Assessing U.S Health Policy 330Self-Check 33114.4 Comparing U.S Health Care to Health Care in Other Countries 33214.4.1 Health Indicators 33214.4.2 Characteristics of the Health System 33214.4.3 Primary Care of Specialty Care-Based System 333Self-Check 334Summary 334Key Terms 335Summary Questions 336Review Questions 337Applying This Chapter 338You Try It 340Endnotes 341Glossary 343Index 359

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