Essentials of the U.S. health care system

Cover
Essentials of The U.S. Health Care System
Copyright
Contents
Preface
Acknowledgments
List of Exhibits
List of Tables
List of Figures
Chapter 1 Major Characteristics of U.S. Health Care Delivery
	Introduction
	Subsystems of U.S. Health Care Delivery
		Managed Care
		Military Medical Care
		Subsystems for Special Populations
		Integrated Systems
		Long-Term Care Delivery
		Public Health System
	Health Care Reform
	Characteristics of the U.S. Health Care System
		No Central Governing Agency; Little Integration and Coordination
		Technology Driven and Focused on Acute Care
		High in Cost, Unequal in Access, and Average in Outcome
		Imperfect Market Conditions
		Government as Subsidiary to the Private Sector
		Fusion of Market Justice and Social Justice
		Multiple Players and Balance of Power
		Quest for Integration and Accountability
		Access to Health Care Services Selectively Based on Insurance Coverage
		Legal Risks Influence Practice Behaviors
	Health Care Systems of Other Developed Countries
		Canada
		Germany
		United Kingdom
	Systems Framework
		System Foundations
		System Resources
		System Processes
		System Outcomes
		System Outlook
	Conclusion
	References
Chapter 2 Foundations of U.S. Health Care Delivery
	Introduction
	What Is Health?
		Illness and Disease
		Acute and Chronic Conditions
		Quality of Life
	Determinants of Health
		Environment
		Behavior and Lifestyle
		Heredity
		Medical Care
	Cultural Beliefs and Values
	Distribution of Health Care
		Market Justice
		Social Justice
		Justice in the U.S. Health Care System
	Strategies to Improve Health
		Healthy People Initiatives
		Public Health
		Focus on Determinants
	Conclusion
	References
Chapter 3 Historical Overview of U.S. Health Care Delivery
	Introduction
	Medical Services in Preindustrial America
		Medical Training
		Medical Practice
		Medical Institutions
	Medical Services in Postindustrial America
		Medical Profession
		The American Medical Association
		Educational Reform
		Development of Hospitals
		Reform of Mental Health Care
	History of Health Insurance
		Worker’s Compensation
		Emergence and Rise of Private Health Insurance
		First Hospital Plan and the Birth of Blue Cross
		First Physician Plan and the Birth of Blue Shield
		Employment-Based Health Insurance
		Failure of National Health Insurance in the United States
		Creation of Medicare and Medicaid
	Medical Services in the Corporate Era
		Corporatization of Health Care Delivery
		Information Revolution
		Globalization
	Era of Health Care Reform
		Health Care Reform in a Flux
	Conclusion
	References
Chapter 4 Health Care Providers and Professionals
	Introduction
	Physicians
		Similarities and Differences Between MDs and DOs
		Generalists and Specialists
		Hospitalists
		Differences Between Primary and Specialty Care
		Work Settings and Practice Patterns
		Imbalance and Maldistribution of Physicians
	Dentists
	Pharmacists
	Other Doctoral-Level Health Professionals
	Nurses
		Advanced-Practice Nurses
	Nonphysician Practitioners
		Value of NPP Services
	Allied Health Professionals
		Technicians and Assistants
		Technologists and Therapists
	Public Health Professionals
	Community Health Workers
	Health Services Administrators
	Patient-Centered Care
	Conclusion
	References
Chapter 5 Technology and Its Effects
	Introduction
	What Is Medical Technology?
	Health Information Technology
		Major Categories
		Electronic Health Records
		The Internet, E-Health, and E-Therapy
		Telemedicine and Remote Monitoring
	Diffusion and Utilization of Medical Technology
		Cultural Beliefs and Values
		Medical Training and Practice
		Insurance Coverage
		Competition Among Providers
	The Government’s Role in Technology Diffusion
		Regulation of Drugs, Devices, and Biologics
		The Affordable Care Act and Medical Technology
		Research on Technology
	Impact of Medical Technology
		Impact on Quality of Care
		Impact on Quality of Life
		Impact on Health Care Costs
		Impact on Access
		Impact on the Structure and Processes of Health Care Delivery
		Impact on Global Medical Practice
		Impact on Bioethics
	Assessment of Medical Technology
		Efficacy
		Safety
		Cost-Effectiveness
	Benefits of Technology Assessment
		Delivering Value
		Cost Containment
		Standardized Practice Protocols
	Conclusion
	References
Chapter 6 Financing and Reimbursement Methods
	Introduction
	Effects of Health Care Financing and Insurance
	Insurance: Its Nature and Purpose
		Basic Insurance Concepts
		Cost Sharing
	Private Insurance
		Group Insurance
		Self-Insurance
		Direct-Purchase Private Insurance
		Managed Care Plans
		High-Deductible Health Plans
	The Affordable Care Act and Private Insurance
	Public Insurance
		Medicare
		Medicaid
		Children’s Health Insurance Program
	Issues with Medicaid
	Reimbursement Methods
		Fee for Service
		Bundled Payments
		Resource-Based Relative Value Scale
		Reimbursement Under Managed Care
		From Retrospective to Prospective Reimbursement
	Payment Reform Initiatives
	National Health Expenditures
	Conclusion
	References
Chapter 7 Outpatient Services and Primary Care
	Introduction
	What Is Outpatient Care?
	Scope of Outpatient Services
		Reimbursement
		Technological Factors
		Utilization Control Factors
		Social Factors
	Outpatient Care Settings and Methods of Delivery
		Private Practice
		Hospital Outpatient Clinics
		Freestanding Facilities
		Mobile Facilities for Medical, Diagnostic, and Screening Services
		Telephone or Internet Triage
		Home Care
		Hospice Care
		Outpatient Long-Term Care Services
		Public Health Services
		Community Health Centers
		Free Clinics
		Alternative Medicine Clinics
	Primary Care
		What Is Primary Care?
		WHO Definition
		IOM Definition
		Domains of Primary Care
		Community-Oriented Primary Care
	Primary Care Around the World
	Effectiveness of Primary Care
		Hospitalizations and Use of Emergency Care
		Cost of Care
		Morbidity
		Mortality
	The Medical Home Strategy
	Use of Information Technology in Primary Care
	Assessment of Community Health Centers
		CHCs’ Quality of Care
		CHCs’ Access to Care
		CHCs’ Cost-Effectiveness
		CHCs and the Affordable Care Act
	Conclusion
	References
Chapter 8 Hospitals
	Introduction
	Evolution of the Hospital in the United States
		Stage 1
		Stage 2
		Stage 3
		Stage 4
		Stage 5
		Stage 6
	Expansion and Downsizing of Hospitals in the United States
	Access and Utilization Measures
		Measures of Access
		Measures of Utilization
		Utilization of Hospital Capacity
	Hospital Employment
	Types of Hospitals
		Community Hospitals
		Public Hospitals
		Private Nonprofit Hospitals
		Private For-Profit Hospitals
		General Hospitals
		Specialty Hospitals
		Psychiatric Hospitals
		Rehabilitation Hospitals
		Children’s Hospitals
		Rural Hospitals
		Teaching Hospitals
		Osteopathic Hospitals
	Licensure, Certification, and Accreditation
	Hospital Organization
	Ethics and Public Trust
		Ethical Challenges
		Addressing Ethical Issues
		Public Trust
	Conclusion
	References
Chapter 9 Managed Care and Integrated Systems
	Introduction
	What Is Managed Care?
		Accreditation and Quality Indicators
	Evolution of Managed Care
	Growth and Transformation of Managed Care
		Private Insurance Enrollment
		Medicare Enrollment
		Medicaid Enrollment
		Managed Care Backlash
		Transformation of Managed Care
	Utilization Control Methods in Managed Care
		Gatekeeping
		Utilization Review
	Types of Managed Care Plans
		HMO Plans
		PPO Plans
		Point-of-Service Plans
	Impact on Cost, Access, and Quality
		Influence on Cost Containment
		Impact on Access
		Influence on Quality of Care
	Integrated Systems
		Integrated Delivery Systems
		Accountable Care Organizations
	Types of Integration
		Integration Based on Major Participants
		Integration Based on Type of Ownership or Affiliation
		Integration Based on Service Consolidation
	Conclusion
	References
Chapter 10 Long-Term Care Services
	Introduction
	What Is Long-Term Care?
		A Variety of Health Care Services
		Individualized Services
		Coordination of Services
		Maximum Possible Functional Independence
		Extended Period of Time
		Holistic Approach
		Quality of Life
	Community-Based Long-Term Care Services
		Home Health Care
		Adult Day Care
		Adult Foster Care
		Senior Centers
		Home-Delivered and Congregate Meals
		Homemaker and Handyman Services
		Emergency Response Systems
		Case Management
	Institutional Long-Term Care
		Retirement Facilities
		Personal Care Facilities
		Assisted Living Facilities
		Skilled Nursing Facilities
		Subacute Care Facilities
		Specialized Care Facilities
	Licensing and Certification of Nursing Homes
		Licensing
		Certification
	Other Long-Term Care Services
		Respite Care
		Restorative Care
		Hospice Care
	The Affordable Care Act and Long-Term Care
	Nursing Home Industry and Expenditures
	Conclusion
	References
Chapter 11 Populations with Special Health Needs
	Introduction
	Framework to Study Vulnerable Populations
	Predisposing Characteristics
		Racial/Ethnic Minorities
		Women and Children
		Geographic Distribution: Rural Health
	Enabling Characteristics
		The Uninsured
		Homelessness
	Need Characteristics
		Mental Health
		Chronic Illness/Disability
		HIV/AIDS
	Eliminating Disparities
	Conclusion
	References
Chapter 12 Cost, Access, and Quality
	Introduction
	Cost of Health Care
	The High Cost of U.S. Health Care
	Reasons for High Health Care Costs
		Third-Party Payment
		Growth of Technology
		Increase in the Elderly Population
		Medical Model of Health Care Delivery
		Multipayer System and Administrative Costs
		Defensive Medicine
		Waste and Abuse
		Practice Variations
	Cost Containment
		Health Planning
		Price Controls
		Peer Review
		Competitive Approaches
		Chronic Disease Prevention and Management
	Unequal Access to Health Care
		Data on Access
		Access Disparities
		Access Initiatives
	Health Care Quality
		Structure
		Process
		Outcome
	Quality Strategies and Initiatives
	Developments in Process Improvement
		Clinical Practice Guidelines
		Cost-Efficiency
		Critical Pathways
		Risk Management
	Patient Safety
	Conclusion
	References
Chapter 13 Health Policy
	Introduction
	What Is Health Policy?
		Different Forms of Health Policies
		Regulatory Tools
		Allocative Tools
	Principal Features of U.S. Health Policy
		Government as Subsidiary to the Private Sector
		Fragmented, Incremental, and Piecemeal Reform
		Pluralistic and Interest Group Politics
		Decentralized Role of the States
		Impact of Presidential Leadership
		Research and Policy Development
	Development of Legislative Health Policy
		Policy Cycle
		Legislative Process
	Critical Policy Issues
		Access to Care
		Providers
		Public Financing
		Access and the Elderly
		Access and Minorities
		Access in Rural Areas
		Access and Low Income
		Smoking and Tobacco Use
		Cost Containment
		Quality of Care
		Mental Health
	National Health Reform
	Conclusion
	References
Chapter 14 The Future of Health Services Delivery
	Introduction
	Forces of Future Change
		Social, Demographic, and Cultural Trends
		Economic Forces
		Political Will, Ideologies, and Legal Rulings
		Technological Innovation
		Global Health Issues
		Ecological Events
	Coverage, Cost, and Access Dilemmas
	The Future of Health Care Reform
		The American Health Care Act
		Will a Single-Payer System Emerge?
		The Cost-Control Imperative
		National Debt
		Medicare’s Generational Impact
	Future Models of Care Delivery
		Value-Based Shared Savings Payments
		Population Health
		Community Outreach
		Virtual Care
		Technology-Driven Home Visits
	Future Workforce Challenges
	Global Challenges
	New Frontiers in Clinical Technology
	Conclusion
	References
Glossary
Index