Shi and singh 7th edition

Healthcare Systems Assignment 1

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

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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.

© f11photo/Shutterstock

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