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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

© f11photo/Shutterstock

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

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

© f11photo/Shutterstock

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