Healthcare Systems Assignment 1
Please choose and answer 1 question from each Chapter among the following questions. You may include copied material from our textbook or from other published materials in your answers, but you must cite your sources to avoid plagiarism. The answers must include the relevant facts, not just your own opinions.
Chapter 1
1. Give at least 3 reasons for lack of integration of essential components of healthcare in the United States (US).
2. Define free market healthcare.
Chapter 2
1. How is public health different from clinical medicine?
2. Define market justice and social justice.
Delivering Health Care in America
A SYSTEMS APPROACH SEVENTH EDITION
Leiyu Shi, DrPH, MBA, MPA Professor, Bloomberg School of Public Health
Director, Johns Hopkins Primary Care Policy Center 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
JONES & BARTLETT LEARNING
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Library of Congress Cataloging-in-Publication Data Names: Shi, Leiyu, author. | Singh, Douglas A., 1946- author. Title: Delivering health care in America : a systems approach / Leiyu Shi, Douglas A. Singh. Description: Seventh edition. | Burlington, Massachusetts : Jones & Bartlett Learning, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2017015329 | ISBN 9781284124491 (pbk.) Subjects: | MESH: Delivery of Health Care | Health Policy | Health Services | United States Classification: LCC RA395.A3 | NLM W 84 AA1 | DDC 362.10973— dc23 LC record available at https://lccn.loc.gov/2017015329
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Contents Preface
List of Exhibits
List of Figures List of Tables
List of Abbreviations/Acronyms
Chapter 1 An Overview of U.S. Health Care Delivery Introduction
An Overview of the Scope and Size of the System
A Broad Description of the System
Basic Components of a Health Care Delivery System
Insurance and Health Care Reform
Role of Managed Care
Major Characteristics of the U.S. Health Care System
Trends and Directions
Significance for Health Care Practitioners
Significance for Health Care Managers
Health Care Systems of Other Countries
Global Health Challenges and Reform
The Systems Framework
Summary
Test Your Understanding
References
PART I System Foundations
Chapter 2 Beliefs, Values, and Health Introduction
Significance for Managers and Policymakers
Basic Concepts of Health
Quality of Life
Risk Factors and Disease
Health Promotion and Disease Prevention
Disease Prevention Under the Affordable Care Act
Public Health
Health Protection and Preparedness in the United States
Determinants of Health
Measures Related to Health
Anthro-Cultural Beliefs and Values
Integration of Individual and Population Health
Summary
Test Your Understanding
References
Chapter 3 The Evolution of Health Services in the United States Introduction
Medical Services in the Preindustrial Era
Medical Services in the Postindustrial Era
Medical Care in the Corporate Era
Globalization of Health Care
The Era of Health Care Reform
Summary
Test Your Understanding
References
PART II System Resources
Chapter 4 Health Services Professionals Introduction
Physicians
Issues in Medical Practice, Training, and Supply
International Medical Graduates
Dentists
Pharmacists
Other Doctoral-Level Health Professionals
Nurses
Advanced Practice Nurses
Midlevel Providers
Allied Health Professionals
Health Services Administrators
Global Health Workforce Challenges
Summary
Test Your Understanding
References
Appendix 4-A List of Professional Associations
Chapter 5 Medical Technology Introduction
What Is Medical Technology?
Information Technology and Informatics
The Internet, E-Health, M-Health, and E-Therapy
Telemedicine, Telehealth, and Remote Monitoring
Innovation, Diffusion, and Utilization of Medical Technology
The Government’s Role in Technology Diffusion
The Impact of Medical Technology
The Assessment of Medical Technology
Directions and Issues in Health Technology Assessment
Health Care Reform and Medical Technology
Summary
Test Your Understanding
References
Chapter 6 Health Services Financing Introduction
The Role and Scope of Health Services Financing
Financing and Cost Control
The Insurance Function
Private Health Insurance
Private Coverage and Cost Under the Affordable Care Act
Public Health Insurance
The Payment Function
National Health Care Expenditures
Current Directions and Issues
Summary
Test Your Understanding
References
PART III System Processes
Chapter 7 Outpatient and Primary Care Services Introduction
What Is Outpatient Care?
The Scope of Outpatient Services
Primary Care
Primary Care and the Affordable Care Act
New Directions in Primary Care
Primary Care Providers
Growth in Outpatient Services
Types of Outpatient Care Settings and Methods of Delivery
Complementary and Alternative Medicine
Utilization of Outpatient Services
Primary Care in Other Countries
Summary
Test Your Understanding
References
Chapter 8 Inpatient Facilities and Services Introduction
Hospital Transformation in the United States
The Expansion Phase: Late 1800s to Mid-1980s
The Downsizing Phase: Mid-1980s Onward
Some Key Utilization Measures and Operational Concepts
Factors That Affect Hospital Employment
Hospital Costs
Types of Hospitals
Expectations for Nonprofit Hospitals
Some Management Concepts
Licensure, Certification, and Accreditation
The Magnet Recognition Program
Ethical and Legal Issues in Patient Care
Summary
Test Your Understanding
References
Chapter 9 Managed Care and Integrated Organizations Introduction
What Is Managed Care?
Evolution of Managed Care
Growth of Managed Care
Efficiencies and Inefficiencies in Managed Care
Cost Control in Managed Care
Types of Managed Care Organizations
Trends in Managed Care
Impact on Cost, Access, and Quality
Managed Care Backlash, Regulation, and the Aftermath
Organizational Integration
Basic Forms of Integration
Highly Integrated Health Care Systems
Summary
Test Your Understanding
References
Chapter 10 Long-Term Care Introduction
The Nature of Long-Term Care
Long-Term Care Services
Users of Long-Term Care
Level of Care Continuum
Home- and Community-Based Services
Institutional Long-Term Care Continuum
Specialized Care Facilities
Continuing Care Retirement Communities
Institutional Trends, Utilization, and Costs
Insurance for Long-Term Care
Summary
Test Your Understanding
References
Chapter 11 Health Services for Special Populations Introduction
Framework to Study Vulnerable Populations
Racial/Ethnic Minorities
The Uninsured
Children
Women
Rural Health
Migrant Workers
The Homeless
Mental Health
The Chronically Ill
HIV/AIDS
Summary
Test Your Understanding
References
PART IV System Outcomes
Chapter 12 Cost, Access, and Quality Introduction
Cost of Health Care
Reasons for Cost Escalation
Cost Containment: Regulatory Approaches
Cost Containment: Competitive Approaches
Cost Containment Under Health Reform
Access to Care
The Affordable Care Act and Access to Care
Quality of Care
Dimensions of Quality
Quality Assessment and Assurance
Public Reporting of Quality
The Affordable Care Act and Quality of Care
Summary
Test Your Understanding
References
Chapter 13 Health Policy Introduction
What Is Health Policy?
Principal Features of U.S. Health Policy
The Development of Legislative Health Policy
The Policy Cycle
Policy Implementation
Critical Policy Issues
Summary
Test Your Understanding
References
PART V System Outlook
Chapter 14 The Future of Health Services Delivery Introduction
Forces of Future Change
The Future of Health Care Reform
The Health Care Delivery Infrastructure of the Future
The Future of Long-Term Care
Global Threats and International Cooperation
New Frontiers in Clinical Technology
The Future of Evidence-Based Health Care
Summary
Test Your Understanding
References
Glossary
Index
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Preface With this Seventh Edition, we celebrate 20 years of serving instructors, students, policymakers, and others, both at home and overseas, with up-to-date information on the dynamic U.S. health care delivery system. Much has changed, and much will continue to change in the future, as the nation grapples with critical issues of access, cost, and quality. Indeed, much of the developing and developed world will also be contending with similar issues.
People in the United States, in particular, have just gotten a taste of a far-reaching health care reform through President Barack Obama’s signature Affordable Care Act (ACA), nicknamed “Obamacare.” To date, this law has produced mixed results that are documented in this new edition.
At the time this edition went to press, we were left with promises of another reform under the slogan “Repeal and replace Obamacare,” a move championed by President Donald Trump, who had made it one of the centerpieces of his presidential campaign. Much remains to be seen as to how this promise will play out.
On May 4, 2017, the U.S. House of Representatives passed the American Health Care Act (AHCA) by a vote of 217 to 213, with Republican support. The bill is likely to undergo significant changes
in the U.S. Senate. Hence, what the new law may eventually look like was unknown at the time this manuscript went to press. As was the case with the ACA, for which the Democratic Party played an exclusive role in its passage, contentious debates, partisanship, and deal making among both Republicans and Democrats have marked the progress in moving the new law through Congress.
Although we have chosen to sidestep any premature speculation about the fate of the ACA and the shape of its replacement, wherever possible, we have presented trends and facts that support certain conclusions. Mainly, experiences and outcomes under the ACA have been highlighted in this edition.
On his first day in office in January 2017, President Trump signed an executive order to “waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the [Affordable Care] Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, health care providers, health insurers, patients, recipients of health care services, purchasers of health insurance, or makers of medical devices, products, or medications.” This executive order effectively repealed small portions of the ACA that deal with taxation and fees.
Going forward, the issues of universal coverage and affordability of insurance and health care will be critical. Under the ACA, approximately 27 million people remained uninsured, even though the uninsurance rate in the United States dropped from 13.3% to 10.9% between 2013 and 2016. The majority of the newly insured individuals were covered under Medicaid, the nation’s safety net health insurance program for the poor.
Another thorny issue will be how to provide health care for the millions of illegal immigrants who obtain services mainly through hospital emergency departments, and through charitable sources to some extent. Is there a better, more cost-effective way to address their needs?
The affordability of health insurance in the non-employment-based private market was severely eroded under the ACA, mainly for those who did not qualify for federal subsidies to buy insurance. The reason for the rate hikes in this segment was that few young and healthy people enrolled in health care plans under the ACA. Consequently, for many people, premium costs rose to unaffordable levels in 2016. People who really needed to use health care enrolled in much larger numbers than healthier individuals. Such an adverse selection prompted the chief executive of Aetna Insurance, Mark Bertolini, to remark that the marketplace for individual health insurance coverage was in a “death spiral.” Some large insurance companies either pulled out of the government- sponsored health care exchanges or were planning to do so because of financial losses sustained under the ACA.
▶ New to This Edition This edition continues to reference some of the main features of the ACA wherever it was important to provide contextual discussions from historical and policy perspectives. Several chapters cover the main provisions of the 21st Century Cures Act, which, after a long delay, was finally passed by Congress and signed by President Obama in December 2016.
As in the past, this text has been updated throughout with the latest pertinent data, trends, and research findings available at the time the manuscript was prepared. Copious illustrations in the form of examples, facts, figures, tables, and exhibits continue to make the text come alive. Following is a list of the main additions and revisions:
Chapter 1 Updates the impact of the Affordable Care Act (ACA)
Critical global health issues and health care reforms in other countries
Chapter 2 Health insurance under the ACA Evaluation of progress made toward the Healthy People 2020 goals Information on global pandemics and infectious diseases
Chapter 3 Expanded section: Reform of mental health care Complete revision of the section: Era of health care reform
Chapter 4 Major issues related to the health care workforce Updated information on nonphysician providers
Chapter 5 New section: Electronic health records and quality of care Global trends in biomedical research and a new table on R&D expenditures New section: Drugs from overseas New section: Health care reform and medical technology
Chapter 6 New section: Private coverage and cost under the Affordable Care Act New section: Medicaid experiences under the ACA New section: Issues with Medicaid New section: Long-term care hospital payment systems
New section: Value-based reimbursement (discusses the MACRA and Medicare Shared Savings Program) Updated current directions and issues in financing
Chapter 7 Research findings using the Primary Care Assessment Tool Measurement and achievement of the patient-centered medical home The impact of community health centers
Chapter 8 New section: Comparative data from the Organization for Economic Cooperation and Development on hospital access and utilization Comparative hospital prices in selected countries New section: Factors that affect hospital employment New section: Rise in bad debts New section: State mental health institutions Update on physician-owned specialty hospitals Medicare designations of sole community hospitals and Medicare- dependent hospitals Patient outcomes at Magnet hospitals New section: Hospital costs
Chapter 9 “Any willing provider” and “freedom of choice” laws under managed care regulations The latest on accountable care organizations
Chapter 10 New section: Recent policies for community- based services
Chapter 11 Updated information on vulnerable subpopulations Expanded coverage on chronically ill patients
Chapter 12 Current issues in health care costs, access, and quality Pay-for-performance in health care Quality initiatives in both the public and private sectors
Chapter 13 Current critical policy challenges Future health policy issues in both the United States and abroad
Chapter 14 Almost all sections have been completely updated New section: No single payer New section: Reforming the reform New section: Universal coverage and access New section: Toward population health
As in the previous editions, our aim is to continue to meet the needs of both graduate and undergraduate students. We have attempted to make each chapter complete, without making it overwhelming for beginners. Instructors, of course, will choose the sections they decide are most appropriate for their courses.
As in the past, we invite comments from our readers. Communications can be directed to either or both authors:
Leiyu Shi Department of Health Policy and Management Bloomberg School of Public Health
Johns Hopkins University 624 North Broadway, Room 409 Baltimore, MD 21205-1996 lshi2@jhu.edu
Douglas A. Singh dsingh@iusb.edu
We appreciate the work of Hailun Liang and Megha Parikh in providing assistance in the preparation of selected chapters of this text.
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List of Exhibits Exhibit 3-1 Evolution of the U.S. Health Care Delivery System
Exhibit 3-2 Groundbreaking Medical Discoveries
Exhibit 4-1 Definitions of Medical Specialties and Subspecialties
Exhibit 4-2 Examples of Allied Health Professionals
Exhibit 6-1 Key Differences Between a Health Reimbursement Arrangement and a Health Savings Account
Exhibit 6-2 Medicare Part A Financing, Benefits, Deductible, and Copayments for 2017
Exhibit 6-3 Medicare Part B Financing, Benefits, Deductible, and Coinsurance for 2017
Exhibit 6-4 Medicare Part D Benefits and Individual Out-of-Pocket Costs for 2017
Exhibit 9-1 The Evolution of Managed Care
Exhibit 11-1 The Vulnerability Framework
Exhibit 11-2 Predisposing, Enabling, and Need Characteristics of Vulnerability
Exhibit 12-1 Regulation-Based and Competition-Based Cost- Containment Strategies
Exhibit 13-1 Key Health Care Concerns of Selected Interest Groups
Exhibit 13-2 Arguments for Enhancing States’ Role in Health Policy Making
© f11photo/Shutterstock
List of Figures Figure 1-1 Basic health care delivery functions.
Figure 1-2 External forces affecting health care delivery.
Figure 1-3 Relationship between price, supply, and demand under free-market conditions.
Figure 1-4 Trends and directions in health care delivery.
Figure 1-5 The systems model and related chapters.
Figure 2-1 The four dimensions of holistic health.
Figure 2-2 The Epidemiology Triangle.
Figure 2-3 WHO Commission on Social Determinants of Health conceptual framework.
Figure 2-4 Integrated model for holistic health.
Figure 2-5 Action model to achieve U.S. Healthy People 2020 overarching goals.
Figure 4-1 Ambulatory care visits to physicians according to physician specialty, 2012.
Figure 4-2 Supply of U.S. physicians, including international medical graduates (IMGs), per 100,000 population, 1985–2013.
Figure 4-3 Trend in U.S. primary care generalists of medicine.
Figure 4-4 IMG physicians as a proportion of total active physicians.
Figure 6-1 Influence of financing on the delivery of health services.
Figure 6-2 Health insurance status of the total U.S. population, 2015.
Figure 6-3 Sources of Medicare financing, 2015.
Figure 6-4 Medicare spending for services, 2015.
Figure 6-5 Medicaid spending for services, 2014.
Figure 6-6 Proportional distribution of U.S. private and public shares of national health expenditures.
Figure 6-7 The U.S. health dollar, 2015.
Figure 7-1 The coordination role of primary care in health care delivery.
Figure 7-2 Percentage of total surgeries performed in outpatient departments of U.S. community hospitals, 1980– 2013.
Figure 7-3 Growth in the number of medical group practices in the United States.
Figure 7-4 Ambulatory care visits in the United States.
Figure 7-5 Medical procedures by location.
Figure 7-6 Demographic characteristics of U.S. home health patients, 2013.
Figure 7-7 Estimated payments for home care by payment source, 2014.
Figure 7-8 Types of hospice agencies, 2014.
Figure 7-9 Coverage of patients for hospice care at the time of admission, 2014.
Figure 8-1 Trends in the number of U.S. community hospital beds per 1,000 resident population.
Figure 8-2 The decline in the number of U.S. community hospitals and beds.
Figure 8-3 Ratio of hospital outpatient visits to inpatient days for all U.S. hospitals, 1980–2013 (selected years).
Figure 8-4 Trends in average length of stay in nonfederal short- stay hospitals, selected years.
Figure 8-5 Average lengths of stay by U.S. hospital ownership, selected years.
Figure 8-6 Breakdown of U.S. community hospitals by size, 2013.
Figure 8-7 Change in occupancy rates in U.S. community hospitals, 1960–2013 (selected years).
Figure 8-8 Proportion of total U.S. hospitals by type of hospital, 2014.
Figure 8-9 Breakdown of U.S. community hospitals by type of ownership, 2013.
Figure 8-10 Hospital governance and operational structures.
Figure 9-1 Percentage of worker enrollment in health plans, selected years.
Figure 9-2 Integration of health care delivery functions through managed care.
Figure 9-3 Growth in the cost of U.S. health insurance (private employers), 1980–1995.
Figure 9-4 Care coordination and utilization control through gatekeeping.
Figure 9-5 Case management function in care coordination.
Figure 9-6 Percentage of covered employees enrolled in HMO plans, selected years.
Figure 9-7 The IPA-HMO model.
Figure 9-8 Percentage of covered employees enrolled in PPO plans, selected years.
Figure 9-9 Percentage of covered employees enrolled in POS plans, selected years.
Figure 9-10 Share of managed care enrollments in employer- based health plans, 2016.
Figure 9-11 Organizational integration strategies.
Figure 10-1 People with multiple chronic conditions are more likely to have activity limitations.
Figure 10-2 Medicare enrollees age 65 and older with functional limitations according to where they live, 2009.
Figure 10-3 Key characteristics of a well-designed long-term care system.
Figure 10-4 Range of services for individuals in need of long-term care.
Figure 10-5 Users of long-term care by age group.
Figure 10-6 Most frequently provided services to home health patients.
Figure 10-7 Sources of payment for home health care, 2014.
Figure 10-8 Changes in the percentages of nursing home residents with various conditions between 2005 and 2015.
Figure 10-9 Distinctly certified units in a nursing home.
Figure 10-10 Sources of financing nursing home care, 2014.
Figure 11-1 Percentage of U.S. live births weighing less than 2,500 grams by mother’s detailed race.
Figure 11-2 Percentage of U.S. mothers who smoked cigarettes during pregnancy according to mother’s race.
Figure 11-3 Alcohol consumption by persons 18 years of age and older.
Figure 11-4 Use of mammography by women 40 years of age and older, 2013.
Figure 11-5 U.S. life expectancy at birth, 1970–2014.
Figure 11-6 Age-adjusted maternal mortality rates.
Figure 11-7 Respondent-assessed health status.
Figure 11-8 Current cigarette smoking by persons 18 years of age and older, age adjusted, 2014.
Figure 11-9 Percentage of female students of total enrollment in schools for selected health occupations, 2013–2014.
Figure 11-10 Contraceptive use in the past month among women 15–44 years old, 2011–2013.
Figure 11-11 AIDS cases reported in the United States, 1987–2014.
Figure 11-12 Federal spending for HIV/AIDS by category, FY 2016.
Figure 12-1 Average annual percentage growth in U.S. national health care spending, 1960–2014.
Figure 12-2 Annual percentage change in CPI and medical inflation, 1975–2014.
Figure 12-3 Annual percentage change in U.S. national health care expenditures and GDP, 1980–2013.
Figure 12-4 U.S. health care spending as a percentage of GDP for selected OECD countries, 1985 and 2014.
Figure 12-5 Life expectancy of Americans at birth, age 65, and age 75, 1900–2014 (selected years).
Figure 12-6 Change in U.S. population mix between 1970 and 2014, and projections for 2030.
Figure 12-7 Increase in U.S. per capita Medicare spending, 1970– 2014 (selected years).
Figure 12-8 Framework for access in the managed care context.
Figure 12-9 The Donabedian model.
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List of Tables Table 1-1 The Complexity of Health Care Delivery
Table 1-2 The Continuum of Health Care Services
Table 2-1 Percentage of U.S. Population with Behavioral Risks
Table 2-2 Annual Percentage Decline in U.S. Cancer Mortality, 1991–2013
Table 2-3 Leading Causes of Death, 2014
Table 2-4 U.S. Life Expectancy at Birth—2002, 2007, and 2014
Table 2-5 Comparison of Market Justice and Social Justice
Table 2-6 Healthy People 2020 Topic Areas
Table 4-1 Persons Employed in Health Service Sites
Table 4-2 Active U.S. Physicians According to Type of Physician and Number per 10,000 Population
Table 4-3 U.S. Physicians According to Activity and Place of Medical Education, 2013
Table 4-4 Mean Annual Compensation for U.S. Physicians by Specialty, May 2016 (in Dollars)
Table 4-5 Percentage of Total Enrollment of Students in Programs for Selected Health Occupations, by Race, 2008–2009
Table 5-1 Examples of Medical Technologies
Table 5-2 MRI Units Available per 1,000,000 Population in Selected Countries, 2014
Table 5-3 Global Biomedical R&D Expenditures in Selected Regions, 2007 and 2012
Table 5-4 Summary of FDA Legislation
Table 6-1 Trends in Employment-Based Health Insurance, Selected Years
Table 6-2 Medicare: Enrolled Population and Expenditures in Selected Years
Table 6-3 Status of HI and SMI Trust Funds (Billions of Dollars), 2012–2015
Table 6-4 U.S. National Health Expenditures in Selected Years
Table 6-5 Percentage Distribution of U.S. National Health Expenditures, 2010 and 2015
Table 7-1 Owners, Providers, and Settings for Ambulatory Care Services
Table 7-2 Growth in Female U.S. Resident Population by Age Groups Between 1980 and 2014 (in Thousands)
Table 7-3 Selected Organizational Characteristics of U.S. Home Health and Hospice Care Agencies in the United States, 2014
Table 7-4 Home Health and Hospice Care Patients Served at the Time of the Interview, by Agency Type and Number of Patients in the United States, 2007
Table 7-5 U.S. Physician Characteristics, 2013
Table 7-6 Principal Reason for Visiting a Physician
Table 7-7 Primary Diagnosis Group
Table 8-1 Share of Personal Health Expenditures Used for Hospital Care
Table 8-2 Discharges, Average Length of Stay, and Average Cost per Stay in U.S. Community Hospitals, 2012
Table 8-3 Inpatient Hospital Utilization: Comparative Data for Selected OECD Countries, 2012 (or Nearest Year)
Table 8-4 Cost per Inpatient Day in Selected Countries, 2012
Table 8-5 Changes in Number of U.S. Hospitals, Beds, Average Size, and Occupancy Rates
Table 8-6 The Largest U.S. Multihospital Chains, 2014
Table 10-1 Trends in Number of Long-Term Care Facilities, Beds/Resident Capacity, and Prices, Selected Years
Table 11-1 Characteristics of U.S. Mothers by Race/Ethnicity
Table 11-2 Age-Adjusted Death Rates for Selected Causes of Death, 1970–2014
Table 11-3 Infant, Neonatal, and Postneonatal Mortality Rates by Mother’s Race (per 1,000 Live Births)
Table 11-4 Selected Health Risks Among Persons 20 Years and Older, 2011–2014
Table 11-5 Vaccinations of Children 19–35 Months of Age for Selected Diseases According to Race, Poverty Status, and Residence in a Metropolitan Statistical Area (MSA), 2014 (%)
Table 11-6 Mental Health Organizations, 2010
Table 11-7 Mental Health Providers by Discipline, Selected Years
Table 11-8 AIDS Cases Reported in the United States, 2010–2014 Cumulative and 2014
Table 12-1 Average Annual Percentage Increase in U.S. National Health Care Spending, 1975–2014
Table 12-2 Total U.S. Health Care Expenditures as a Proportion of GDP and per Capita Health Care Expenditures (Selected Years, Selected OECD Countries; per Capita Expenditures in U.S. Dollars)
Table 12-3 Visits to Office-Based Physicians, 2012
Table 12-4 Number of Health Care Visits According to Selected Patient Characteristics, 2014
Table 12-5 Dental Visits in the Past Year Among Persons 18–64 Years of Age, 2014
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List of Abbreviations/Acronyms
A AALL—American Association of Labor Legislation
AAMC—Association of American Medical Colleges
AA/PIs—Asian Americans and Pacific Islanders
AAs—Asian Americans
ACA—Affordable Care Act
ACNM—American College of Nurse-Midwives
ACO—accountable care organization
ACS—American College of Surgeons
ADA—American Dental Association
ADC—adult day care
ADLs—activities of daily living
ADN—associate’s degree nurse
AFC—adult foster care
AHA—American Hospital Association
AHRQ—Agency for Healthcare Research and Quality
AIANs—American Indians and Alaska Natives
AIDS—acquired immunodeficiency syndrome
ALF—assisted living facility
ALOS—average length of stay
AMA—American Medical Association
AMDA—American Medical Directors Association
ANA—American Nurses Association
APCs—ambulatory payment classifications
APN—advanced practice nurse
ARRA—American Recovery and Reinvestment Act
ASPR—Assistant Secretary for Preparedness and Response
B
BBA—Balanced Budget Act
BPCI—bundled payments for care improvement
BSN—baccalaureate degree in nursing
BWC—Biological and Toxin Weapons Convention
C CAH—critical access hospital
CAM—complementary and alternative medicine
CBO—Congressional Budget Office
CCAH—continuing care at home
CCRC—continuing care retirement center/community
CDC—Centers for Disease Control and Prevention
CDSS—clinical decision support system
CEO—chief executive officer
CEPH—Council on Education for Public Health
CER—comparative effectiveness research
CF—conversion factor
CHAMPVA—Civilian Health and Medical Program of the Department of Veterans Affairs
CHC—community health center
CHIP—Children’s Health Insurance Program
CMGs—case-mix groups
C/MHCs—community and migrant health centers
CMS—Centers for Medicare and Medicaid Services
CNA—certified nursing assistant
CNM—certified nurse-midwife
CNS—clinical nurse specialist
COBRA—Consolidated Omnibus Budget Reconciliation Act
CON—certificate of need
COPC—community-oriented primary care
COTA—certified occupational therapy assistant
COTH—Council of Teaching Hospitals and Health Systems
CPI—consumer price index
CPOE—computerized provider order entry
CPT—Current Procedural Terminology
CQI—continuous quality improvement
CRNA—certified registered nurse anesthetist
CT—computed tomography
D DC—Doctor of Chiropractic
DD—developmental disability
DDS—Doctor of Dental Surgery
DGME—Direct Graduate Medical Education
DHHS—U.S. Department of Health and Human Services
DHS—Department of Homeland Security
DMD—Doctor of Dental Medicine
DME—durable medical equipment
DO—Doctor of Osteopathic Medicine
DoD—Department of Defense
DPM—Doctor of Podiatric Medicine
DRA—Deficit Reduction Act
DRGs—diagnosis-related groups
DSM-5—Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
DTP—diphtheria/tetanus/pertussis (vaccine)
E EBM—evidence-based medicine
EBRI—Employee Benefit Research Institute
ECG—electrocardiogram
ECU—extended care unit
ED—emergency department
EHRs—electronic health records
EMT—emergency medical technician
EMTALA—Emergency Medical Treatment and Active Labor Act
ENP—Elderly Nutrition Program
ERISA—Employee Retirement Income Security Act
ESRD—end-stage renal disease
F FD&C Act—Federal Food, Drug, and Cosmetic Act
FDA—Food and Drug Administration
FMAP—Federal Medical Assistance Percentage
FPL—federal poverty level
FTE—full-time equivalent
FY—fiscal year
G GAO—General Accounting Office
GDP—gross domestic product
GP—general practitioner
H HAART—highly active antiretroviral therapy
HCBS—home- and community-based services
HCBW—home- and community-based waiver
HCH—Health Care for the Homeless
HCPCS—Healthcare Common Procedures Coding System
HDHP—high-deductible health plan
HDHP/SO—high-deductible health plan with a savings option
HEDIS—Healthcare Effectiveness Data and Information Set
HHRG—home health resource group
HI—hospital insurance
HIAA—Health Insurance Association of America
Hib—Haemophilus influenzae serotype b
HIO—health information organization
HIPAA—Health Insurance Portability and Accountability Act
HIT—health information technology
HITECH— Health Information Technology for Economic and Clinical Health Act
HIV—human immunodeficiency virus
HMO—health maintenance organization
HMO Act—Health Maintenance Organization Act
HPSAs—health professional shortage areas
HPV—human papillomavirus
HRA—health reimbursement arrangement
HRQL—health-related quality of life
HRSA—Health Resources and Services Administration
HSA—health savings account
HTA—health technology assessment
HUD—U.S. Department of Housing and Urban Development
I
IADLs—instrumental activities of daily living
ICF—intermediate care facility
ICF/IID—intermediate care facilities for individuals with intellectual disabilities
ICF/MR—intermediate care facilities for the mentally retarded
ID—intellectual disability
IDD—intellectual/developmental disability
IDEA—Individuals with Disabilities Education Act
IDS—integrated delivery systems
IDU—injection drug use
IHR—International Health Regulations
IHS—Indian Health Service
IME—Indirect Medical Education
IMGs—international medical graduates
IOM—Institute of Medicine
IPA—independent practice association
IRB—institutional review board
IRF—inpatient rehabilitation facility
IRMAA—Income-Related Monthly Adjustment Amount
IRS—Internal Revenue Service
IS—information systems
IT—information technology
IV—intravenous
L LPN—licensed practical nurse
LTC—long-term care
LTCH—long-term care hospital
LVN—licensed vocational nurse
M MA—Medicare Advantage
MA-PD—Medicare Advantage Prescription Drug Plan
MA-SNP—Medicare Advantage Special Needs Plan
MACPAC—Medicaid and CHIP Payment and Access Commission
MACRA—Medicare Access and CHIP Reauthorization Act
MBA—Master of Business Administration
MCOs—managed care organizations
MD—Doctor of Medicine
MDS—Minimum Data Set
MedPAC—Medicare Payment Advisory Com- mission
MEPS—Medical Expenditure Panel Survey
MERS—Middle East respiratory syndrome
MFP—Money Follows the Person
MHA—Master of Health Administration
MHS—multihospital system
MHSA—Master of Health Services Administration
MIPS—Merit-based Incentive Payment System
MLP—midlevel provider
MLR—medical loss ratio
MMA—Medicare Prescription Drug, Improvement, and Modernization Act
MMR—measles/mumps/rubella vaccine
MPA—Master of Public Administration/Affairs
MPFS—Medicare Physician Fee Schedule
MPH—Master of Public Health
MRHFP—Medicare Rural Hospital Flexibility Program
MRI—magnetic resonance imaging
MSA—metropolitan statistical area
MS-DRGs—Medicare severity diagnosis-related groups
MSO—management services organization
MSSP—Medicare Shared Savings Program
MUAs—medically underserved areas
N NAB—National Association of Boards of Examiners of Long-Term Care Administrators
NAPBC—National Action Plan on Breast Cancer
NCCAM—National Center for Complementary and Alternative Medicine
NCCIH—National Center for Complementary and Integrative Health
NCHS—National Center for Health Statistics
NCQA—National Committee for Quality Assurance
NF—nursing facility
NGC—National Guideline Clearinghouse
NHC—neighborhood health center
NHE—national health expenditures
NHI—national health insurance
NHS—national health system
NHS—U.K. National Health Service
NHSC—National Health Service Corps
NICE—National Institute for Health and Clinical Excellence
NIH—National Institutes of Health
NIMH—National Institute of Mental Health
NP—nurse practitioner
NPP—nonphysician practitioner
NRP—National Response Plan
O OAM—Office of Alternative Medicine
OBRA—Omnibus Budget Reconciliation Act
OD—Doctor of Optometry
OI—opportunistic infection
OPPS—Outpatient Prospective Payment System
OT—occupational therapist
OWH—Office on Women’s Health
P P4P—pay-for-performance
PA—physician assistant
PACE—Program of All-Inclusive Care for the Elderly
PAHPA—Pandemic and All-Hazards Preparedness Act
PASRR—Preadmission Screening and Resident Review
PBMs—pharmacy benefits managers
PCCM—primary care case management
PCGs—primary care groups
PCMH—patient-centered medical home
PCP—primary care physician
PDP—stand-alone prescription drug plan
PERS—personal emergency response system
PET—positron emission tomography
PFFS—private fee-for-service
PharmD—Doctor of Pharmacy
PhD—Doctor of Philosophy
PHI—personal health information
PHO—physician–hospital organization
PhRMA—Pharmaceutical Research and Manufacturers of America
PMPM—per member per month
POS—point-of-service (plan)
PPD—per-patient day (rate)
PPM—physician practice management
PPO—preferred provider organization
PPS—prospective payment system
PRO—peer review organization
PSO—provider-sponsored organization
PSRO—professional standards review organization
PsyD—Doctor of Psychology
PTA—physical therapy assistant
PTCA—percutaneous transluminal coronary angioplasty
PT—physical therapist
Q QALY—quality-adjusted life year
QI—quality indicator
QIO—quality improvement organization
R R&D—research and development
RBRVS—resource-based relative value scales
RN—registered nurse
RUGs—resource utilization groups
RVUs—relative value units
RWJF—Robert Wood Johnson Foundation
S SAMHSA—Substance Abuse and Mental Health Services Administration
SARS—severe acute respiratory syndrome
SAV—small area variations
SES—socioeconomic status
SGR—sustainable growth rate
SHI—socialized health insurance
SMI—supplementary medical insurance
SNF—skilled nursing facility
SPECT—single-photon emission computed tomography
SSI—Supplemental Security Income
STD—sexually transmitted disease
T TAH—total artificial heart
TANF—Temporary Assistance for Needy Families
TCU—transitional care unit
TEFRA—Tax Equity and Fiscal Responsibility Act
TPA—third-party administrator
TQM—total quality management
U UCR—usual, customary, and reasonable
UR—utilization review
V VA—Department of Veterans Affairs
VBP—Value-Based Purchasing
VHA—Veterans Health Administration
VISN—Veterans Integrated Service Network
W WHO—World Health Organization
WIC—Special Supplemental Nutrition Program for Women, Infants, and Children
Chapter opener photo: © f11photo/Shutterstock
CHAPTER 1 An Overview of U.S. Health Care Delivery
LEARNING OBJECTIVES
■ Understand the basic nature of the U.S. health care system. ■ Outline the key functional components of a health care delivery system. ■ Get a basic overview of the Affordable Care Act. ■ Discuss the primary characteristics of the U.S. health care system. ■ Emphasize why it is important for health care practitioners and managers to understand the
intricacies of the health care delivery system. ■ Get an overview of health care systems in selected countries. ■ Point out global health challenges and reform efforts. ■ Introduce the systems model as a framework for studying the health care system in the United
States.
The U.S. health care delivery system is a behemoth that is almost impossible for any single entity to manage and control.
▶ Introduction The United States has a unique system of health care delivery that is unlike any other health care system in the world. Almost all other developed countries have national health insurance programs run by the government and financed through general taxes. Nearly all citizens in such countries are entitled to receive health care services. Such is not yet the case in the United States, where Americans are not automatically covered by health insurance.
Though U.S. health care is often called a system because is has various features, components, and services, it may be misleading to talk about the American health care delivery “system,” because a true, cohesive system does not exist (Wolinsky, 1988). Indeed, a major feature of the U.S. health care system is its fragmented nature, as different people obtain health care through different means. The system has continued to undergo periodic changes, mainly in response to concerns regarding costs, access, and quality.
Describing health care delivery in the United States can be a daunting task. To facilitate an understanding of the structural and conceptual basis for the delivery of health care services, this text is organized according to the systems framework presented at the end of this chapter. Also, for the sake of simplicity, the mechanisms of health care delivery in the United States are collectively referred to as a system throughout this text.
The main objective of this chapter is to provide a broad understanding of how health care is delivered in the United States. Examples of how health care is delivered in other countries are also presented for the sake of comparison. The overview presented here introduces the reader to several concepts discussed more extensively in later chapters.
▶ An Overview of the Scope and Size of the System
TABLE 1-1 demonstrates the complexity of health care delivery in the United States. Many organizations and individuals are involved in health care. To name just a few: educational and research institutions, medical suppliers, insurers, payers, and claims processors to health care providers. A multitude of providers are involved in the delivery of preventive, primary, subacute, acute, auxiliary, rehabilitative, and continuing care. A large number of managed care organizations (MCOs) and integrated networks now provide a continuum of care, covering many of the service components.
TABLE 1-1 The Complexity of Health Care Delivery
Education/Research Suppliers Insurers Providers Payers Government
Medical schools Dental schools Nursing programs Physician assistant programs Nurse practitioner programs Physical therapy, occupational therapy, speech therapy programs Research organizations Private foundations U.S. Public Health Service (Agency for Healthcare Research and Quality, Agency for Toxic Substances and Disease Registry, Centers for Disease Control and Prevention, Food and Drug Administration, Health Resources and Services
Pharmaceutical companies Multipurpose suppliers Biotechnology companies
Managed care plans Blue Cross/Blue Shield plans Commercial insurers Self-insured employers Medicare Medicaid Veterans Affairs Tricare
Preventive Care Health departments Primary Care Physician offices Community health centers Dentists Nonphysician providers Subacute Care Subacute care facilities Ambulatory surgery centers Acute Care Hospitals Auxiliary Services Pharmacists Diagnostic clinics
Blue Cross/Blue Shield plans Commercial insurers Employers Third-party administrators State agencies
Public insurance financing Health regulations Health policy Research funding Public health
Administration, Indian Health Service, National Institutes of Health, Substance Abuse and Mental Health Services Administration) Professional associations Trade associations
X-ray units Suppliers of medical equipment Rehabilitative Services Home health agencies Rehabilitation centers Skilled nursing facilities Continuing Care Nursing homes End-of-Life Care Hospices Integrated Managed care organizations Integrated networks
The U.S. health care delivery system is massive, with total employment that exceeded 16.4 million people in 2010 in various health delivery settings. This number included more than 838,000 professionally active doctors of medicine (MDs), 70,480 osteopathic physicians (DOs), and 2.6 million active nurses (U.S. Census Bureau, 2012). The majority of health care and health services professionals (5.98 million) work in ambulatory health service settings, such as the offices of physicians, dentists, and other health practitioners, medical and diagnostic laboratories, and home health care service locations. Smaller proportions of these professionals are employed by hospitals (4.7 million) and nursing and residential care facilities (3.13 million). The vast array of health care institutions in the United States includes approximately 5,795 hospitals, 15,700 nursing homes, and 13,337 substance abuse treatment facilities (U.S. Census Bureau, 2012).
In 2015, 1,375 federally qualified health center grantees, with 188,851 full-time employe