Wiley Pathways Introduction to U.S. Health Care The Structure of Management and Financing of the U.S. Health Care System

by Pointer, Dennis D.; Williams, Steve; Isaacs, Stephen L.; Knickman, James R.; Barr, Tracy L.

• ISBN13: 9780471790754
• ISBN10: 0471790753
• Edition: 1st
• Format: Paperback
• Copyright: 2006-11-10
• Publisher: WILEY

Summary

You can get there Where do you want to go? You might already be working in a health care or business setting. You may be looking to expand your skills. Or, you might be setting out on a new career path. Wherever you want to go, Introduction to U.S. Health Care will help you get there. Easy-to-read, practical, and up-to-date, this text not only helps you learn fundamental concepts of the American health care system; it also helps you master the core competencies and skills you need to succeed in the classroom and beyond. The book's brief, modular format and variety of built-in learning resources enable you to learn at your own pace and focus your studies. With this book, you will be able to: * Understand the role of governing boards and the challenges they face. * Compare and contrast the primary-care and specialty-care models. * Explore recent health care reforms that affect the primary-care model. * Examine how we pay for health care. * Learn about the many different roles played by the health care workforce. * Discover how medical miracles are financed. * Trace the evolution of hospitals throughout the nation's history and through their current state. * Assess the reasons behind the growing reliance on ambulatory care. * Understand who needs long-term care, why, and what the choices are. * Explore the challenges of providing health services for society's most vulnerable groups. * Identify obstacles in caring for the uninsured. * Examine the types of managed care organizations, such as HMOs, PPOs, and POS plans. * Explore current and future challenges for the health care industry. * Understand the impact of new and emerging laws, regulations, and initiatives. Wiley Pathways helps you achieve your goals When it comes to learning about health care, not everyone is on the same path. But everyone wants to succeed. The new Wiley Pathways series in Health Care Management helps you achieve your goals with its brief, inviting format, clear language, and focus on core competencies and skills. The books in this series--Introduction to U.S. Health Care, Health Care Economics, Health Care Management, and Health Care Law and Ethics--offer a coordinated curriculum for learning health care management. Learn more at www.wiley.com/go/pathways.

Author Biography

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

Table of Contents

Part I: Foundations	1	(46)
The U.S. Health Care System	1	(29)
Introduction	2	(1)
Gauging the Size of the Health Care Industry	2	(2)
Self-Check	4	(1)
Balancing Public and Private Health: Health Care Organizations	4	(5)
Protecting Populations: Public Health Care Organizations	5	(1)
Serving Individuals: Private Health Care Organizations	5	(3)
Self-Check	8	(1)
Identifying Health Systems	9	(2)
Types of Health Systems	9	(1)
Forming Health Systems	10	(1)
Self-Check	11	(1)
Classifying Health Care Industry Sectors	11	(4)
Financing	11	(1)
Institutional Providers	12	(1)
Individual Providers	12	(1)
Public Health Agencies	13	(1)
Enablers	13	(1)
Suppliers	13	(1)
Regulators	13	(1)
Self-Check	14	(1)
Defining Health and Disease	15	(4)
Causes of Disease	15	(1)
Analyzing U.S. Health and Disease Status	16	(2)
Self-Check	18	(1)
Accessing Health Services in the United States	19	(11)
Triggers to Utilizing the Health Care System	19	(1)
Factors Affecting Utilization	20	(1)
The Role of Health Services Administration Research	21	(2)
Self-Check	23	(1)
Summary	23	(1)
Key Terms	23	(2)
Summary Questions	25	(2)
Review Questions	27	(1)
Applying This Chapter	28	(1)
You Try It	29	(1)
Boards and Governance	30	(17)
Introduction	31	(1)
Understanding the Role of Governing Boards	31	(4)
Determining Mission, Vision, and Values	32	(1)
Ensuring Management Performance	33	(1)
Ensuring Quality of Care	34	(1)
Ensuring Financial Health	34	(1)
Self-Check	35	(1)
Board Composition, Structure, and Infrastructure	35	(4)
Health Systems	36	(1)
Hospitals	37	(1)
Self-Check	38	(1)
Challenges Facing Boards	39	(8)
Liability of Board Members	39	(1)
Reporting and Disclosure of Accounting Information	40	(1)
Conflict of Interest	40	(1)
Board Performance	41	(1)
Self-Check	41	(1)
Summary	41	(1)
Key Terms	41	(3)
Summary Questions	44	(1)
Review Questions	44	(1)
Applying This Chapter	45	(1)
You Try It	46	(1)
Part II: Health Care Organization and Financing	47	(63)
Health Care Provision	47	(27)
Introduction	48	(1)
Health Provision at a Glance: Specialty-Care versus Primary-Care	48	(2)
Primary-Care Model	49	(1)
Specialty-Care Model	49	(1)
Self-Check	50	(1)
Primary Care Reforms in the United States	50	(2)
Benefits of the Primary Care Model	51	(1)
Predicting Primary Care	52	(1)
Future in the United States	52	(1)
Self-Check	52	(1)
Performance of the Primary Care Model in the United States	52	(3)
Accessibility	53	(1)
Continuity	53	(1)
Comprehensiveness	54	(1)
Coordination	54	(1)
Accountability to the Community	54	(1)
Its Effect on Primary Care Providers	55	(1)
Self-Check	55	(1)
Primary Care Innovations	55	(2)
The Primary Care Team	55	(1)
Chronic Care Model and Collaborative Care	56	(1)
Self-Check	57	(1)
Identifying the PCP	57	(3)
Permeable Boundaries Between Generalist, Specialist, and Other Functions	58	(1)
Specialists Providing Primary Care	58	(1)
Generalists Providing Secondary Care	58	(1)
Hospitalists Dedicated to General Inpatient Care	59	(1)
Nonphysician Primary Care Clinicians	60	(1)
Self-Check	60	(1)
PCPs and the Populations They Serve	60	(14)
Health Profession Shortage Areas (HPSAs)	61	(1)
Federal and State Strategies	62	(1)
Self-Check	63	(1)
Summary	63	(1)
Key Terms	64	(2)
Summary Questions	66	(2)
Review Questions	68	(4)
Applying This Chapter	72	(1)
You Try It	73	(1)
Financing the U.S. Health Care System	74	(36)
Introduction	75	(1)
Changing Economic Dynamics	75	(5)
Increasing Expenditures	76	(1)
Reasons for the Increase	77	(2)
Affecting How Health Care is Financed	79	(1)
Self-Check	80	(1)
Flow of Funds through the System	80	(4)
Where the Money Comes From	80	(2)
Where the Money Goes	82	(1)
How It Gets There	82	(2)
Self-Check	84	(1)
Examining Who Has Health Insurance	84	(3)
Self-Check	87	(1)
Categorizing Health Insurance Plans	87	(5)
Indemnity plan	88	(1)
Service Benefit Plan	89	(1)
Managed Care Plan	90	(1)
Self-Check	91	(1)
Private Insurance Coverage: Voluntary Health Insurance (VHI)	92	(2)
Types of VHI Plans	92	(1)
Coverage Variations in VHI Plans	93	(1)
Self-Check	94	(1)
Government Insurance Programs: Medicare and Medicaid	94	(5)
Social Health Insurance: Medicare	94	(2)
Welfare Insurance: Medicaid	96	(2)
Self-Check	98	(1)
Health Maintenance Organizations (HMOs)	99	(11)
HMO Growth	99	(1)
HMO Models	99	(2)
Self-Check	101	(1)
Summary	101	(1)
Key Terms	102	(2)
Summary Questions	104	(3)
Review Questions	107	(1)
Applying This Chapter	108	(1)
You Try It	109	(1)
Part III: Health Care Resources	110	(55)
The Health Care Workforce	110	(31)
Introduction	111	(1)
Sizing Up the Workforce	111	(3)
Self-Check	114	(1)
Understanding the Role of the Physician	114	(4)
Counting All Doctors	114	(2)
Specialists	116	(1)
General practitioners	117	(1)
Hospitalists	118	(1)
Self-Check	118	(1)
Training Doctors	118	(3)
Medical School	119	(1)
Residency and Fellowship	119	(2)
Self-Check	121	(1)
Nurses	121	(4)
Registered Nurses (RNs)	121	(2)
Training Requirements	123	(1)
Where the Nurses are	123	(1)
Other Nursing Personnel: LPNs and LVNs	124	(1)
Self-Check	125	(1)
Other Independent Health Professionals	125	(4)
Dentists	126	(1)
Chiropractors	126	(1)
Optometrists	127	(1)
Podiatrists	127	(1)
Pharmacists	128	(1)
Self-Check	129	(1)
Working in Concert with Physicians	129	(12)
Physical Therapists	129	(1)
Physician Assistants	130	(1)
Self-Check	131	(1)
Summary	131	(1)
Key Terms	132	(3)
Summary Questions	135	(2)
Review Questions	137	(2)
Applying This Chapter	139	(1)
You Try It	140	(1)
Research and Technology	141	(24)
Introduction	142	(1)
Understanding Medical Research	142	(7)
Advances in Knowledge	143	(2)
Advances in Diagnostic Techniques	145	(1)
Advances in Treatment Options and Therapeutic Interventions	146	(1)
Advances in Pharmaceuticals	147	(1)
Advances in Information and Communication Technologies	147	(2)
Self-Check	149	(1)
Research Facilities	149	(4)
Public Research Facilities: National Institutes of Health (NIHs)	149	(2)
Academic Health Centers	151	(1)
Private Research Facilities	152	(1)
Core Facilities	152	(1)
Self-Check	153	(1)
Funding Research: Knowing Where the Money Comes From	153	(2)
Public Funds	153	(1)
Private Donors/Benefactors	154	(1)
Self-Check	155	(1)
Assessment and Challenges of Continuing Medical Advancement	155	(10)
The Shift from Public to Private Research Endeavors	155	(1)
Issues Regarding Research in General Internal Medicine	155	(1)
The Impact on Academic Health Centers	156	(1)
Cost To Health Care	156	(1)
Self-Check	157	(1)
Summary	158	(1)
Key Terms	158	(1)
Summary Questions	159	(2)
Review Questions	161	(1)
Applying This Chapter	162	(2)
You Try It	164	(1)
Part IV: The Health Care Delivery System	165	(121)
Hospitals in the U.S.	165	(21)
Introduction	166	(1)
The Evolution of Hospitals in the U.S.	166	(4)
Forming Hospitals: the Refuge Stage	166	(2)
Hospitals As the Center of Health Care: Physician Workshop Stage	168	(1)
Becoming More Business Oriented: The Business Stage	169	(1)
Managing Complex Systems: The System Stage	169	(1)
Self-Check	170	(1)
Components and Cost of American Hospitals	170	(3)
Hospital Components	170	(1)
Hospital Costs	171	(1)
Self-Check	172	(1)
Classifying Hospitals	173	(4)
Length of Stay: Short and Long-Term Hospitals	174	(1)
Type of Service: General and Specialty Hospitals	174	(1)
Ownership: Nonprofit, Proprietary, and Governmental	175	(1)
Self-Check	176	(1)
Care and Competition in the Twenty-First Century	177	(9)
Hospital Care	177	(1)
Competition in Health Care	178	(1)
Self-Check	179	(1)
Summary	179	(1)
Key Terms	180	(2)
Summary Questions	182	(1)
Review Questions	183	(1)
Applying This Chapter	184	(1)
You Try It	185	(1)
Ambulatory Care	186	(20)
Introduction	187	(1)
Understanding Ambulatory Care	187	(4)
The Growing Reliance on Ambulatory Care	188	(1)
Accessing Ambulatory Care	189	(1)
Paying For Ambulatory Care	189	(1)
Ambulatory Care Accreditation	190	(1)
Self-Check	191	(1)
Ambulatory Care Settings and Providers	191	(6)
Physician Offices: Solo and Group Practices	192	(1)
Emergency Rooms and Hospital Outpatient Departments	193	(1)
Urgent Care Facilities	194	(1)
Same-Day Surgery Centers	194	(1)
Community Health Centers and Clinics	195	(1)
Student Health Centres or Clinics	196	(1)
Occupational Health Programs	197	(1)
Self-Check	197	(1)
Home Health and Visiting Nurse Agencies	197	(9)
Self-Check	199	(1)
Summary	199	(1)
Key Terms	200	(1)
Summary Questions	201	(1)
Review Questions	202	(2)
Applying This Chapter	204	(1)
You Try It	205	(1)
Long-Term Care	206	(24)
Introduction	207	(1)
Understanding Long-Term Care	207	(2)
Typical Long-Term Care Services	207	(1)
People Who Need Long-Term Care	208	(1)
Self-Check	209	(1)
Personal Care Facilities	209	(5)
Assisted Living Facilities	210	(1)
Continuing Care Retirement Communities (CCRCs)	210	(1)
Congregate Care Facilities	211	(1)
Nursing Homes	211	(2)
Alzheimer's/Dementia Facilities	213	(1)
Self-Check	214	(1)
Community-Based and Home Health Care	214	(4)
Receiving Care at Home	215	(1)
Taking Advantage of Community-Based Care	216	(2)
Self-Check	218	(1)
Rehabilitation Centers	218	(1)
Self-Check	219	(1)
Hospice Care	219	(11)
Hospice Service Providers	219	(1)
Hospice Services	220	(1)
Accessing Hospice Care	221	(1)
Financing Hospice Care	222	(1)
Self-Check	222	(1)
Summary	222	(1)
Key Terms	222	(3)
Summary Questions	225	(1)
Review Questions	226	(1)
Applying This Chapter	227	(2)
You Try It	229	(1)
Caring For Special Populations	230	(24)
Introduction	231	(1)
Caring For Mentally Ill Patients	231	(8)
Providing Mental Health Services	231	(3)
Paying For Mental Health Services	234	(1)
Challenges To Accessing And Providing Care For Mentally Ill Patients	235	(2)
Legal Issues Regarding Health Care for Mentally Ill Patients	237	(2)
Self-Check	239	(1)
Homeless Patients	239	(2)
Health Issues in the Homeless Population	240	(1)
Challenges in Providing Health Care to Homeless	240	(1)
Self-Check	241	(1)
Veterans	241	(2)
Health Issues For Veterans	241	(1)
Challenges in Providing Health Care to Veterans	242	(1)
Self-Check	243	(1)
Immigrants	243	(2)
Challenges in Providing Health Care to Immigrants	243	(1)
Legal Issues Regarding Health Care for Immigrants	244	(1)
Self-Check	245	(1)
Caring For Other Special Populations	245	(9)
People With AIDS and HIV	245	(1)
Victims of Violence	246	(1)
Self-Check	246	(1)
Summary	247	(1)
Key Terms	247	(2)
Summary Questions	249	(2)
Review Questions	251	(1)
Applying This Chapter	251	(2)
You Try It	253	(1)
Caring For Uninsured Patients	254	(15)
Introduction	255	(1)
Identifying Uninsured Patients	255	(2)
Self-Check	257	(1)
Accessing Health Care When Uninsured	257	(3)
Community Health Centers and Clinics	257	(1)
Urgent Care Facilities	257	(1)
Emergency Rooms	258	(2)
Self-Check	260	(1)
Challenges in Providing Health Care to Uninsured Patients	260	(3)
Health-Related Challenges	260	(1)
Financial-Related Challenges	261	(2)
Self-Check	263	(1)
Legal Issues and Uninsured Patients	263	(6)
Self-Check	264	(1)
Summary	264	(1)
Key Terms	264	(2)
Summary Questions	266	(1)
Review Questions	267	(1)
Applying This Chapter	267	(1)
You Try It	268	(1)
Managed Care	269	(17)
Introduction	270	(1)
Understanding Managed Care	270	(3)
Controlling Costs	270	(1)
Ensuring Quality	271	(1)
Understanding How Managed Care Works	272	(1)
Self-Check	272	(1)
Types of Managed Care Organizations	273	(3)
Health Maintenance Organizations (HMOs)	273	(2)
Preferred Provider Organizations (PPOs)	275	(1)
Point-Of-Service (POS) Plans	275	(1)
Self-Check	276	(1)
Assessing the Performance of Managed Care	276	(10)
Impact on Quality and Cost	276	(1)
Impact on Physicians and Health Care Providers	277	(1)
The Future of Managed Care	278	(1)
Self-Check	278	(1)
Summary	279	(1)
Key Terms	279	(2)
Summary Questions	281	(1)
Review Questions	282	(2)
Applying This Chapter	284	(1)
You Try It	285	(1)
Part V: Challenges Of US Health Care	286	(55)
Promoting Health And Preventing Disease	286	(33)
Introduction	287	(1)
Growing Complexity of the U.S. Health Care System	287	(3)
The Effect on Governing Boards	288	(1)
The Challenge to Health Systems	289	(1)
Self-Check	290	(1)
Financing Health Care	290	(4)
Government Initiatives	291	(1)
Evolving Health Insurance and Health Plans	292	(1)
Funding Medicare	293	(1)
Self-Check	294	(1)
Aging Population	294	(2)
Demand and Cost for Short-Term Care	294	(1)
Demand For Long-Term Care	295	(1)
Self-Check	296	(1)
Challenges for Primary Care	296	(6)
The Cult of Specialization	296	(2)
Too Few Generalists; Too Many Specialists	298	(1)
The Unexpected Impact of Managed Care	298	(1)
The Lack of Government Direction Regarding Primary Care Physicians	299	(1)
Changing Medical Models	300	(2)
Self-Check	302	(1)
Examining The Underserved: Rural and Inner-City Areas	302	(3)
Lack of Racial and Ethnically Diverse Doctors	302	(1)
Declining Numbers of General Practitioners	303	(1)
Location of Practices	303	(1)
Lack of Coordinated Effort to Address Shortage	304	(1)
Role of Gender on Choice of Practice Location	305	(1)
Self-Check	305	(1)
Fixing the Problem of the Underserved	305	(4)
Bolstering Ethnically Diverse Workforce	305	(1)
Changing Medical Education System	306	(1)
Changing Reimbursement Strategies of Medicare and Medicaid	307	(1)
Changes in Existing Direct Federal and State Programs	307	(1)
Relying on the Impact of Managed Care	307	(1)
Self-Check	308	(1)
Other Challenges	309	(10)
Advancing Technology	309	(1)
Shortage of Nurses	309	(1)
Evolving Public Health Threats	310	(1)
Declining Financial Health of Hospitals	310	(1)
Self-Check	311	(1)
Summary	311	(1)
Key Terms	311	(2)
Summary Questions	313	(2)
Review Questions	315	(1)
Applying This Chapter	316	(2)
You Try It	318	(1)
Public Health Policy	319	(22)
Introduction	320	(1)
Public Health Services	320	(8)
Federal Health Agencies	322	(1)
State Health Agencies	323	(2)
Local Health Agencies	325	(2)
Private Initiatives in Public Health Policy	327	(1)
Self-Check	328	(1)
Federal and State Health Laws	328	(2)
Federal Statutes and Regulations	328	(1)
State Statutes and Regulations	329	(1)
Self-Check	330	(1)
Assessing U.S. Health Policy	330	(2)
Self-Check	331	(1)
Comparing U.S. Health Care to Health Care in Other Countries	332	(9)
Health Indicators	332	(1)
Characteristics of the Health System	332	(1)
Primary Care of Specialty Care-Based System	333	(1)
Self-Check	334	(1)
Summary	334	(1)
Key Terms	335	(1)
Summary Questions	336	(1)
Review Questions	337	(1)
Applying This Chapter	338	(2)
You Try It	340	(1)
Endnotes	341	(2)
Glossary	343	(16)
Index	359