health care in america

disease

Diseaseis an objective designation or diagnosis made by a medical or health professional.

Mind-body medicine

"enhance the mind's capacity to affect bodily function and symptoms" (NCCAM, 2007). These interventions include support groups such as Alcoholics Anonymous or cancer support groups, meditation, faith medicine (healing practices, such as prayer, that appeal to a supernatural power), and creative therapies such as art.

Explain why we see increasing demand for health care despite some inadequate returns on investment.

(1) Patients are not rational consumers. They do not always know the "value" of health care services that they demand. However, patients will utilize them anyway for any perceived benefit. (2) Patients do not usually pay for care at the time they receive it. When insurance is paying for care, patients are less likely to question if they are receiving enough "value" for the service, (i.e., if it is worth purchasing). (3) Health care is a business, and providers are willing to offer services that may be of marginal value in the aggregate but may benefit an individual patient. Hospitals, doctors, and other providers have to sell services to make money and keep people employed.

Has modern medicine been effective in the late twentieth century and early twenty-first century? Explain.

- Compared to its accomplishments in the early twentieth century, modern medicine may have relatively little impact on health today. -Health care costs have increased faster than general inflation almost every year. We spend about 2½ times more on health care per capita than other developed countries. -Further, health care expenditures are not necessarily greater for those who live longer, at least past the age of 70, unless that person is institutionalized (living in a nursing home) at age 70. -Recent studies have estimated substantial life expectancy gains and decreases in mortality that outweigh the costs. -Advances were made in the treatment of acute myocardial infarction. Significant gains in survival rates were achieved in the 1980s and early 1990s, but survival rates have remained much the same since 1996 (Skinner, Staiger, & Fisher, 2006). This study also found that higher spending was actually associated with lower survival rates. Cost-effectiveness of treatments may have also changed over time.

Discuss the trends in our current health status related to mortality, chronic diseases, disability, and so forth.

- this nation has enjoyed in-creases in life expectancy at 65 years of age for both genders from 1970 through 2007 -Disability rates have also declined for the population over age 65. However, numbers of people with chronic conditions are increasing for all adults over age 45, and disability rates are increasing for the age group 50-64 years old. -Rates of neck and back problems among 50-64 year olds increased over 30 percent between 1997 and 1999, and again between 2005 and 2007 (Martin et al., 2010). -Rates of diseases such as diabetes, hypertension, and neurological conditions have increased as well. -Americans also need more assistance with activities of daily living and instrumental activities of daily living at younger ages (Martin et al., 2010). These trends indicate that the burden of disease is growing as well as the prevalence, with more individuals requiring assistance in the form of canes, walkers, wheelchairs, or other medical equipment. -Rates of overweight and obesity are increasing as well, contributing to increases in chronic conditions (see Figure 3-6). We are living longer, but we are producing more, not fewer, disabled or chronically ill individuals who are living longer and consuming even more health resources—we are not curing disease. -our life expectancy is not increasing at any-where near the same rate as our expenditures on health care. Health care expenditures have more than tripled since 1990 -preventive public health measures have been the most cost-effective health care interventions to date. The returns on investment for immunizations, prena-tal care, smoking cessation, and cholesterol control are relatively high

Much that could be done to prevent disease and promote health, using knowledge and technology, is not done.

-As a society, we have not been very successful at encouraging individuals to exercise, change their diets, stop smoking (especially among the young), or adopt behaviors that could dramatically alter the burden of disease. Finally, many health care needs are under-met (not enough home health care for the elderly), whereas others are over-met (too many acute care hospital beds).

Define home health, assisted living, and hospice in your own words and describe the trends in the use of or provision of these services.

-Assisted living is another type of long-term care service for patients who have limita-tions in some activities of daily living or instrumental activities of daily living, but do not need full-time nursing care. About 50 percent of assisted living facilities are for-profit. They pay rent and an additional fee for those services. -Home health care is care that is provided in a person's private residence. The per-son must be home bound and receive a prescription from a provider for home health services. Home health care is designed to promote, maintain, or restore health, or can be prescribed to minimize the effects of a disability and/or illness. The elderly are the primary consumers of home health care. there was a substantial increase in the number and variety of ser-vices offered by home health care providers. This trend was sustained by an aging society and generous Medicare reimbursement. Home health care has been less ex-pensive than inpatient care, so Medicare and other insurers have been willing to pay for home health care. Medicare-certified home health care agencies increased from 1,700 in 1962 to 6,100 in 1992, to 10,027 in 1996. After passage of the Balanced Budget Act of 1997, which changed payments from a cost basis to a very strict pro-spective payment system, the number of certified home health agencies (HHAs) had decreased to 6,861 by 2001. Due to further revisions to the Balanced Budget Act in 2000 and 2001, HHAs began re-entering the market after 2002. There were 9,284 certified home health agencies in 2007. -Hospice care is palliative care to the terminally ill (those with a life expectancy of 6 months or less) and their families. This care involves the medical relief of pain and supportive services that can be provided in an inpatient setting, such as a hospital or nursing home or in a patient's home. These programs address the emotional, social, financial, and legal needs of patients and their families. It is frequently used for the treatment of terminal cancer and AIDS patients. Patients in hospice cannot receive curative care. There has been substantial growth in the number of hospices, partially attributable to an increase in third-party reimbursement for hospice's lower costs in comparison to hospital or nursing home care.

challenges of using QALYs

-Different treatments may have different values of QALYs -answers based on hypothetical health states may not reflect what a person will actually believe if he or she is ever in that state. For example, a person may believe that losing both legs would reduce his quality of life by 50 percent, but if that unlikely event happened, he might find that his quality of life was either better or worse than he expected. -Opinions could also change over time as a person adjusts to the condition. -QALYs also do not take into account externalities, both positive and negative. Externalities are treatments that may have a beneficial or negative impact on more people than just the one receiving the treatment. For example, those who are vaccinated for a communicable disease exert a positive externality on those who are not because the un-immunized cannot contract the disease from the immunized. That benefit to the un-immunized would not be captured in a QALY measurement. -the value of a QALY or the cost-effectiveness of a QALY may differ depending on who is placing value on a per-son's life, whether it is the patient, the family, a physician, an insurer, or a government system.

Describe the benefits and disadvantages of group physician practice (to both patient and provider)

-First, physicians who enter established group practices do not have any overhead costs. -Group practices have better leverage and ability to negotiate contracts with insurers and suppliers due to patient volume and the ability to hire professional staff. -Group practices offer economies of scale that solo practitioners do not have, allowing group practices to obtain better value on their purchases and receive lower reimbursement than a solo practitioner can afford. -Physicians working in group practices also have more flexible work schedules than solo practitioners. They are usually able to share on-call time with other physicians and have less responsibility for administrative tasks and more opportunities for continuing education credits within the group practice structure. -Additionally, physicians in group practices have less financial risk than solo practitioners. -Group practices are also more likely to hire professional management and personnel to work on billing and reimburse-ment. -patients can receive all or most of their care under one roof, par-ticularly in large multi-specialty group practices. -Patients can have laboratory work completed, obtain records and second opinions, and be referred to specialists within the same practice. - Disadvantages: -Physicians have less individual freedom, in that they must work with others including administrators. -Shared risk can also be a disadvantage from a malpractice or litigation standpoint. -The potential for higher incomes is also reduced in a group practice setting. -physicians in group practice settings face higher patient loads, which may inhibit the physician-patient relationship, and physicians in a group practice may receive less money than a solo practitioner due to the income distribution arrangements -longer waits to see their providers, and more bureaucracy. - ---Group practices may also have high provider turnover, leading to less continuity of care for patients. -patients believe that they have less of a relationship with their physicians and may feel rushed during their appointments.

homeopathy and naturopathy medicine

-Homeopathy is the use of "very low doses of drugs that produce patient signs or symptoms" as a means of curing them -naturopathy is the all-natural treatments such as herbal medicine, massage, acupuncture, manual manipulation, hydrotherapy, and aromatherapy. Naturopaths believe that natural treatments can help the human body to heal itself.

Explain the different ways that hospitals can be classified. What is the most common type in each category?

-Hospitals can be classified based on characteristics such as length of stay, size, owner-ship type, type of care delivered, and whether they have one or more approved residency programs, for instance in a teaching hospital. length of stay: can be long-stay or short-stay hospitals. Short-stay are most common (less than 30 days). A majority of short-stay hospitals are voluntary, not-for-profit, community, general hospitals Size: the number of beds they have. Hospitals with fewer beds are gaining market share. Over half of the hospitals in the United States have 100 beds or less. There are 2.7 beds per 1,000 people in the United States, and the average size of a hospital is approximately 164 beds. ownership: Most (58% in 2008) hospitals are voluntary or not-for-profit. Not-for-profit hospitals may be stand-alone community hospitals, part of a hospital chain, part of a church affiliation or religious hospital group, or part of a not-for-profit managed care organization. New York-Presbyterian Hospital in New York City is the nation's largest not-for-profit, nonsectarian hospital. Proprietary hospitals are for-profit, are subject to taxes, and are often owned by shareholders, and many of these corporations are traded on the stock exchange. HCA is the largest for-profit hospital corporation in the United States type of care delivered: The most common type of hospital is a general medical/surgical allopathic hospital. Hospitals may have a special focus, depending on the types of patients received. teaching hospitals: There are approximately 400 teaching hospitals in the United States. A teaching hospital must have at least one approved residency program for medicine or dentistry.

osteopathic medicine

-Osteopathic physicians are trained to use drugs, devices, and surgery like MDs, but, traditionally, they have focused on treating the person holistically rather than focusing on symptoms or dis-eases. -In osteopathic medicine, holistic means that structure influences function; if there is a problem in one part of the body's structure, function in that area, and possibly in other areas, may be affected. Thus, part of a DO's training includes combining manual musculoskeletal manipulation with other medical treatment. -This system of hands-on techniques helps alleviate pain, restores motion, supports the body's natu-ral functions, and influences the body's structure to help it function more efficiently. Another integral tenet of osteopathic medicine is the body's innate ability to heal it-self. -aimed at reducing or eliminating the impediments to proper structure and function so the self-healing mechanism can assume its role in restoring a person to health. -Doctor of Osteopathy (DO)

Explain the shift in physician practice arrangements over time

-Physician practices are the predominant mode of ambulatory care. Practice arrangements have many variations, but a shift has been taking place away from solo physician practices toward more group practices over the last 20 years. This shift has caused the number of solo physician practices to decline

Discuss the differences between skilled nursing, nursing facility, sub-acute, and post-acute care

-Skilled nursing facilities (SNFs) provide short-term skilled nursing care on an inpatient basis, usually following hospitalization. These facilities provide the most intensive care available outside of a hospital. Most SNFs are in nursing homes, but many hospitals may also have SNF beds. -Nursing facilities provide health-related services on a regular basis to individuals who do not require the degree of care or treatment that a skilled nursing unit is designed to provide. This type of "nursing home" care comes to mind when thinking of people residing in nursing homes. -Sub-acute care is delivered in the inpatient setting to patients who are suffering from an injury or acute illness or an exacerbation of an existing condition. It may be used after a hospital stay or in place of an acute care hospital stay. The treatment is goal-oriented and is designed around one or more specific conditions or complex treat-ments. The patient will work with physical and occupational therapists at least 6 hours a day to regain as much functioning as possible. Sub-acute care can be provided in nursing homes and rehabilitation and long-term care hospitals -Post-acute care is similar to sub-acute care but always occurs following an acute care hospitalization and does not have to be provided in an inpatient setting. It may be given in nursing homes, rehabilitation and long-term care hospitals, or through outpatient physical and occupational therapy. The treatment and rules for inpatient post-acute care are the same as for sub-acute care. The patient must undergo at least 6 hours of therapy per day if the patient is a Medicare beneficiary

Explain why chronic diseases have increased over time

-The human species is not genetically suited to living in a high-technology-driven society -These diseases result from mal-adaptation to our environment and to an increasingly sedentary lifestyle.

What are the top causes of death by age group? How do these change across age groups?

-The top causes of death in the United States are heart disease, cancer, and stroke -Infant deaths are mostly caused by congenital anomalies, sudden infant death syndrome (SIDS), and short gestation. -Young children are more likely to die because of injuries, cancer, and congenital anomalies. -Teens and adults up to age 35 suffer mostly violent deaths from unintentional injury, homicide, and suicide. -Adults ages 35-54 usually die from unintentional injuries, cancer, or heart disease. -adults 55 and over usually die from chronic disease-related conditions: heart disease, cancer, and stroke

3 pillars of healthcare system (the iron triangle)

-access is the potential or ability to use health care services -cost is the price of health care services -quality refers to how good or bad the health care services are at the time of delivery. *Each of these factors can be described at the micro level, such as between the individual patient and provider, and at the macro, or system, level*

complementary and alternative medicines

-alternative therapies in place of conventional medicine. Although some scientific evidence has been produced to demonstrate the effectiveness of some alternative therapies, most of the practices that constitute complementary and alternative medicine still have not been proven as effective and/or safe. The National Institutes of Health (NIH), National Center for Com-plementary and Alternative Medicine (NCCAM), classifies CAM into five domains: whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine.

Rehabilitative care

-example of the increasing demands placed on the health care system and the increasing importance of physical medicine. With each generation, there appear to be increasing demands for health care technology and decreasing tolerance of illness. Thus, with each new generation the expectations of the health care system, or access to high-quality care, increase.

long-term care

-focuses upon the treatment of chronic illnesses and disability. Demand for long-term care services has increased in recent years and will become even more critical as our population ages and people live longer. -Long-term care is generally less expensive and less intensive than acute hospital care. Long-term care services include nursing homes, home health care, assisted living facilities, and hospice care.

reasons for measuring health status of groups and populations

-insurance companies try to use previous indicators of health status to determine the health care costs of their applicant pool. -to compare the effectiveness of various medical care devices and services -can also help public and private health care providers detect unmet need and identify high-risk populations to determine how to plan and market services -often used to support arguments for and against universal health care and health insurance systems.

stakeholders in healthcare

-is an individual or group that has an investment or personal interest in something -In health care, any changes in the macro system affect the stakeholders. These stakeholders therefore attempt to influence the health care system and create changes that will be beneficial for them. The interaction between stakeholders affects the "iron triangle" of access, cost, and quality

tertiary care

-is often delivered at large medical centers, referral hospitals, and teaching hospitals. -Tertiary care hospitals do provide almost all levels of service, including primary and secondary care. They also perform complex medical procedures such as transplants, open-heart surgery, neurosurgery, and advanced cancer treatment, and are likely to have intensive care and critical care units such as neonatal intensive care, cardiac intensive care, and burn units.

environmental components of health

-physical -social -economic

common social problems targeted by healthcare

-poverty, substance abuse, and unemployment -illiteracy, racism, and violent crime -health habits and diet, spouse abuse, injury caused by guns

major stakeholders in healthcare industry

-providers (e.g., physicians, nurses, hospitals, chiropractors), consumers (patients), insurers (e.g., health maintenance organizations [HMOs], preferred provider organizations [PPOs], BlueCross/Blue Shield, Prudential), businesses (employers), and government (regu-lation, Medicaid/Medicare). -Providers and consumers are the frontline participants in the health care system, because most health care contacts are made between doc-tors and other providers and patients. Insurers, or third-party payers, pay hospitals and physicians and other providers for patient care. Individuals and/or employers pay premiums to the insurers to cover health care costs for themselves or their employees. Hence, businesses or employers also act as insurers for their employees. The federal and state governments also act as insurers through Medicare, funded and adminis-tered at the federal level, and Medicaid, which is a federal-state matching program. Medicare and Medicaid are government-run financing programs that provide insur-ance primarily for the elderly and poor, respectively. In addition to acting as an insurer, the government also acts as a provider in the Department of Defense, Department of Veteran Affairs, Bureau of Prisons, and other federal and state hospitals and clinics. The federal government regulates health care providers by requiring licenses and is a major funding source for health-related research

What role does smoking have on health status? What are the implications of outlawing smoking?

-smoking is the number one risk factor for premature death. -The heart attack rate is two to five times greater for smokers than nonsmokers, depending on age. -Smoking also has a dose-response effect, meaning the higher the dose (or the more you smoke), the more likely the outcome (heart attack rate). -Smoking has a great impact on health care costs. -Smokers age 50 and older are two times more likely than former smokers to die within the next 15 years. -If everyone quit smoking, our Social Security payments would increase because people would live longer. -Smokers pay into Social Security once they begin working, until retirement at age 62-65. Smokers pay into the system and die early without receiving its full benefits. Therefore, if everyone quit smoking, our taxes would increase. -If more people start living longer, most likely they will develop other chronic conditions and limitations and will require more health care treatment, leading to higher health care costs and a larger burden on the Medicare pro-gram. -Smokers also help to pay for many governmental programs through taxes paid on cigarettes (also called a sin tax). Were smoking to be eliminated, the government would have to end many of its programs or find another tax base.

Describe the different types of ownership in health care, and give examples of each.

-the largest percentage of hospitals in the United States is nongovernmental and not-for-profit. If an organization has not-for-profit tax status, no profit can accrue to any shareholders. -pproximately 19 percent of com-munity hospitals are for-profit enterprises. Some examples of national for-profit hospital corporations are Hospital Corporation of America (HCA) and Tenet Health Care Corpo-ration (Tenet). HCA owns 163 hospitals in the United States and England and had profits of $28 billion in 2008 (HCA, 2010). HCA has a board of directors, and investors can buy shares in the company on the stock exchange. Other for-profit enterprises include insurance companies such as Aetna and United Healthcare, nursing homes (two-thirds of nursing homes are for-profit), as well as pharmaceutical companies, home health companies, durable medical equipment suppliers and private physician practices. Pri-vate professional practices include physicians, dentists, psychologists and psychiatrists, and chiropractors, among others.

why US infant mortality rate is different from other countries

-the nation's poor lack access to early prenatal care compared to those with higher in-comes, and large-scale public health interventions directed at reducing infant mortality among the poor are not nearly as aggressive as those in other countries. -other countries may measure their infant mortality rates differently from the United States, excluding lower birth weight and/or shorter gestation births or deaths that occur within the first 24 hours after birth. -Although poverty is a major contributing factor to higher rates, a combination of lack of access to prenatal care and personal behaviors, as well as inherent discrimination within the U.S. health care system all contribute to infant mortality disparities -the black-white disparity, where the black rate is nearly three times that of whites, explains in part why the U.S. infant mortality rate is relatively higher. -blacks and American Indians have higher infant mortality than whites. However, Hispanics in the United States, who also have high rates of poverty, have infant mortality and low birth weight rates comparable to whites.

Health

A state of complete physical, mental, and social well-being and not merely the absence of disease

Describe the benefits and disadvantages of solo physician practice

Advantages: -Physicians delivering services in their own practice have more autonomy. -Solo practitioners have more discretion about what office hours they keep during the week, the location of their offices, their choice of office staff, and what insurance companies they will accept. -Finally, solo practitioners report better personal relationships with patients and a lower level of bureaucracy. Disadvantages: -Solo practitioners have to compete with group physician practices. -Solo practitioners bear the full financial risk for their practices. -Further, private practice physicians may need to be on-call more often for their patients than physicians who practice in a group. ---Solo practitioners need to make arrangements for other physicians to cover their patients when they are on vacation or otherwise unavailable to their patients -Third, solo practitioners have more administrative responsibilities. Solo practice physicians are required to perform more of the billing, documentation, and any other administrative tasks that are required in their private offices.

allopathic medicine

Allopathic medicine is conventional or traditional scientific medicine. Doctors trained in allopathic medicine use drugs, devices, and surgery to treat diseases to produce alterations in the paths of diseases. -physicians who have received their Doctorate of Medicine (MD)

Define opportunity cost, and give an example of your own of an opportunity cost in health care.

An opportunity cost is the value of an alternative decision that was forgone once a choice has been made. For example, when we go to the doctor, we incur many opportunity costs such as our time spent elsewhere. We could be working and earning money, and those lost wages become an opportunity cost

Discuss the concept of diminishing marginal returns in health care and why this is a concern for the U.S. health care system.

For each additional dollar spent, we obtain less of a gain in output, whether it is measured by increased life expectancy, lower mortality, or better quality of life. Part of the reason for this diminishing marginal return is that there is a distinction between health care and medical care. -Health care includes factors that affect lifestyle, genetics and socioeconomic factors (Fuchs, 2004). Medical care in general has less impact on over-all health, with many differences in outcomes attributable to other factors such as genetics and lifestyle -Waste, fraud, and defensive medicine direct the health care dollar away from payment for services that bring real returns -When observing level of disability as an outcome for treatments to reduce disability, there is also no indication that returns are positive. -Some suggest that spending large amounts on cures after the presence of illness, rather than spending scarce dol-lars on less-expensive preventive measures and education, produces the diminishing marginal returns - As Skinner and colleagues noted above, we are not obtain-ing as much value out of treatments for heart attacks as we did 20 years ago. We practice what Enthoven coined, in the 1970s, as "flat-of-the-curve" medicine. He posited that we have reached the point in many health care treatments where we do not experience any additional increase in health status for additional spending. However, we continue to supply and demand these services despite having no gains in health status

how do mortality rates differ by subgroups?

Generally, female mortality rates are lower than male mortality rates, while the poor have higher death rates than the non-poor, and older people have higher death rates than younger people. Mortality rates can be adjusted for age, sex, race, and other characteristics of the population to make the rates comparable across these factors

illness

Illness is a subjective notion that focuses on how patients feel

summary of chapter one

In this chapter we discussed the definition of health. The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." Our health is predominately influenced by heredity or genetics, the environment, lifestyle, and the organization and delivery of health care services. The "iron triangle" of health care includes access, cost, and quality. Access is the potential or ability to use health care services. Cost is the price of health care services. Quality refers to how good or bad the health care services are at the time of delivery.There are several types of care that consumers are able to access. They include health education and prevention, primary care, secondary care, tertiary care, emer-gency care, and long-term care. We also discussed the differences and similarities be-tween allopathic medicine, osteopathic medicine, and complementary and alternative medicine. Although some scientific evidence has been produced to demonstrate the effectiveness of some alternative therapies, most of the practices that constitute com-plementary and alternative medicine still have not been proven as effective and/or safe.The major stakeholders in the United States health care system include providers, consumers, insurers, businesses, and government. Each group plays an important role in the health care industry, with several of the groups playing two or three roles. For instance, the state and federal governments act as insurer, consumer, and provider of health care services. Employers both consume health care services and reimburse pro-viders when they are self-insured. Each group is affected by the many problems with our health care system. All current problems affect access, cost, and quality and the dynamic interaction among them

chapter two summary

In this chapter, we discussed the definition of health, how health status is measured, how health status measures are used to influence health care systems and compare different countries, challenges to measuring health status, other factors that influ-ence health status, the existence of disparities in health care, and mental illness in the United States. Measuring health status is complicated, but it is vital to organizing our health care system and improving the health of our nation. We must know the health care needs of the nation's subpopulations to provide the appropriate treatment options and be able to plan for the health needs of future generations.

Describe modern medicine's strategy against diseases.

Modern medicine approaches the treatment of diseases using sophisticated technology, investing large amounts of money, and focusing on curative treatments. 5 main reasons for high-tech approach: -technical response: mechanistic approach to the treatment of disease -space shot mentality -cure more palatable than prevention: Many people continue to engage in unhealthy behaviors with the hope that they will not develop problems or if they do, a treatment (cure) will be available -inertia: Our current system, both in its educa-tion of professionals and its modes of delivery, are geared toward curing rather than preventing. It will be difficult to change the way we think and behave let alone change the direction of medical thinking. -Zero sum game the high-tech approach has its consequences, including rapidly rising expendi-tures, a concentration of resources in acute hospitals, a concentration of resources on "interesting" medical conditions at the expense of the elderly, disabled, and mentally ill, and a medical education system that emphasizes specialty training and cures rather than primary care and prevention.

State government preform these functions

Regulation/licensing •Mental health services •Vital statistics (births, deaths, divorces, marriages) •Public health laboratories •Communicable disease control programs •Environmental health •Maternal and child health •Health planning and health education

the cultural war-polarization of the nation

The United States is composed of individuals with differing values and opinions that often guide thoughts and decisions and heavily influence how people feel about different social issues, including the provision and regulation of health care. There is a philosophical di-vide between those who favor government involvement in our lives and those who view it as intrusion. Those who believe strongly in egalitarianism and government programs to improve the common good are often at odds with those who believe that personal responsibility and freedom will lead to the common good. There are also moral struggles in our society over entitlements and welfare, abortion, stem cell research, gun ownership, homosexuality, and many other issues, some of which are fought in the health policy arena Secularists, people who believe that religion should not play a role in the public and governments' decisions, are at the polar opposite from those who believe in traditional religion and its influence in their lives and decisions. it affects U.S. health care policy in a number of ways: the interpretation of the Constitution and the rights granted to U.S. citizens (right to health or health care); the role of health care in the economy and the level of regulation needed; the battle between personal freedom and property rights versus government ownership and control; and the role of the federal government versus the role of state governments in creating policy. Citizens of the United States have no constitutional right to health care or health insurance. the Constitution does not contain the word "health." It does contain a clause in the preamble to "promote the general welfare." This broad phrase leads many Americans to believe that health care is a right or should be a right. To some extent, our nation does grant a right to health care. The Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) mandates that hospitals with Emergency Departments that participate in Medicare evaluate any patient who seeks care, regardless of the patient's ability or willingness to pay, and that they treat or stabilize anyone who is found to have an emergency medical condition. This act means that any person who goes to an emergency room will be seen by a health care professional In addition to disagreement over whether citizens have a right to health care, there is also disagreement regarding the appropriate role of government in the marketplace (competition vs. regulation). The United States has a private-public health care system where we struggle to maintain the free-market system while simultaneously ensuring the welfare of our citizens. Determining the appropriate amount of government regu-lation or involvement in the health care system is what is referred to as the "health care tug-of-war"

explain the various government roles in healthcare

The government is one of the most important stakeholders in the U.S. health care system. It performs several important roles, including financing, delivering, and regulating the delivery of health care. The government—federal, state, and local combined—is the largest single payer of health care. -Financing: State governments jointly fund the Medicaid program along with the federal government. Federal and state governments also provide funding for long-term mental health services, medical education, community health centers, public health programs. Local governments subsidize public hospitals and local public health departments. -Delivering: The federal government oper-ates facilities for American Indians through the Indian Health Service; for military service personnel through Army, Navy, and Air Force hospitals; for veterans through the Department of Veterans Affairs hospitals and facilities; and for indigent or unin-sured patients through federally qualified health care centers and rural health clinics. State governments operate mental hospitals, health departments, and medical schools. Local governments operate municipal/county hospitals and local health departments -regulating: government involvement in the health care marketplace is justified when the free market does not "work," meaning that there are market failures (discussed in Chapter 15) and when the health, safety, and welfare of its citizens are affected. The federal government is also involved in setting implementing regulations for Medicare and Medicaid providers, prohibiting discrimination by providers, and determining what drugs and devices are sold. The Food and Drug Administration (FDA) regulates drugs and medical devices. State governments regulate the insurance industry, license health care personnel and facilities, and establish health codes. Local governments also establish local health codes

the rise in health care costs and expenditures has been uncontrollable by any intervention tried to date.

The increase in expenditure growth slowed in the 1990s because of a lower overall (i.e., for the entire U.S. economy) inflation rate, but it is increasing at rates last seen in the early 1990s. Managed care had some modest suc-cess in slowing the rise in costs and expenditures in the 1990s, but the success was not sustained. *The three major factors driving rising health care costs and expenditures are an aging population, a growth in technology, and an increase in demand for and expectations of health care. We have little or no control over these aspects of the health care system*

Explain the decline in infectious diseases in the 1800s and what factors contributed to this decline.

The major causes of death from the sixteenth to the early twentieth centuries were infectious diseases such as pneumonia, tuberculosis, diarrhea and enteritis, cholera, and diphtheria. However, trends over time demonstrate that mortality from these diseases was in rapid decline before medical interventions such as antibiotics and vaccinations were available. Factors such as improved nutrition, clean water, and appropriate sewage disposal as well as declining birth rates were responsible for the decline in mortality and improvement in health status currently enjoyed in the twenty-first century

Describe how we use modern medicine to cope with disease.

The technical category includes modern scientific medicine. Only by this mode do we see disease altered in a predictable way. However, even in the twenty-first century relatively few health care treatments have been subjected to rigorous evaluation. -we frequently use modern scientific medicine whether or not it is effective as a means of coping with disease. After all, doing something may be better than doing nothing, regardless of the odds of success - Randomized clinical trials, which are the gold standard for evaluating the efficacy of a treatment, have only been conducted on a minority of modern health care treatments, mostly related to pharmaceuticals. The rest of modern medicine falls into a large gray area where doctors practice from training, experience, and clinical intuition. -Clinical trials can possibly reduce this variation by proving or disproving the efficacy of any given treatment method. However, we still have many treatments whose efficacy is often questionable that are still being used - (1) shifting from fee-for-service and indemnity coverage to managed care; and (2) standard protocols and formularies of treatment. These strategies conflict with the use of ineffective health care treatments to help individuals cope with disease. In fact, these strategies were designed to limit the amount of ineffective health care treatments that are used as coping mechanisms

The distribution of health services varies across the U.S. population.

This inequality includes the disparity between the poor and the rich, rural settings versus urban areas, and others. The U.S. health care system is described by its critics as a "two-tiered" system, where different levels of access to care and different levels of quality care exist based on the demographic and socioeconomic characteristics of the individual. Health care disparities are a growing area of health services research

several types of medicine and alternative healing

Traditional medicine is practiced by physicians, both allopathic and osteopathic. Complementary and alternative medicine is practiced by clinicians, including chiropractors, acupuncturists, homeopaths, naturopaths, and faith healers.

principle problems table of US healthcare system

We are spending too much on health care services, not too little. •We are spending too little on health care services, not too much. •The rise in costs has been uncontrollable by any interventions tried to date. •The distribution of health services is highly variable throughout the population. •Much that could be done to prevent disease and promote health, using available knowledge and techniques, is not done. •Many health care needs are under-met (e.g., not enough home health care for the infirm elderly), while others are over-met (e.g., too many hospital beds

summary for chapter 3

We started the chapter by examining whether modern medicine has relatively little impact on health today. We examined the questions of whether we are spending too much on health care and whether we are receiving value from our expenditures in improved health and longer life expectancy. What type of value do we receive for our health spending? The United States spends an enormous amount of money on health care services; however it is unclear whether we receive appropriate value for our in-vestment. In addition, experts are troubled because we cannot sustain these increases without draconian shifts in spending away from other essential budget priorities. Further, health care expenditures are not necessarily greater for those who live longer or are healthier. Overall, we are not getting adequate returns on our investment in health care, although demand for health care is increasing.There are several reasons for this increase in demand, including these: (1) Patients are not rational consumers; (2) patients do typically bear the full cost of the care at the time they receive it; and, (3) health care is a profit-driven business, and providers are willing to offer services that may provide minimal value overall even though they benefit an individual patient.Health care services, like many other goods and services, have diminishing mar-ginal returns. For each additional dollar spent, we obtain less of a gain in output, whether it is measured by increased life expectancy, lower mortality, or better qual-ity of life. In other words, each year we spend more on health care, but the returns decrease over time. This may be due to waste, fraud, and defensive medicine that direct money away from payment for services that bring real returns.Despite these challenges, there are many positive trends in our health status as mea-sured by life expectancy and infant mortality. We have experienced increases in life expectancy at 65 years of age for both genders from 1970 through 2007, and disability rates have also declined for the population over age 65. However, while we are living longer, we are also experiencing more, not fewer, chronically ill individuals who are living longer and consuming even more health resources.Today, the leading causes of death are heart disease, cancer, and stroke. These chronic diseases are the main killers of the last half of the twentieth century into the twenty-first century and result from the mal-adaptation to our environment and to an increasingly sedentary lifestyle.Many of the issues that we face regarding health status are a reflection of modern medicine. The modern health care industry focuses on using sophisticated technology to cure diseases, investing large amounts of money to treat conditions that are a result of lifestyle choices, and emphasizing curative rather than preventive treatments

Explain the influence of age, sex, race, and poverty on health status.

age: as adults grow older, their health status deteriorates, and they need more health care services. After the age of 65, chronic conditions such as arthritis, hypertension, hear-ing impairment, heart disease, orthopedic problems, cataracts, and diabetes increase. This rise results in an increase in health care expenditures for these conditions. gender: women on most other measures of health status are less "healthy" than males, but women live longer than men. Many believe that this difference is not due to true biological differences favoring men. Rather, it is an artifact (i.e., it is not real). These differences are explained by the care-seeking behavior of women who go to physicians more often than men so that they are more likely to be diagnosed with an illness. In addition, many believe that society "allows" women more than men to adopt the sick role race: Blacks have higher rates of heart disease and stroke than do whites. Some postulate that there is likely a biological explanation given the high prevalence of hypertension among blacks. This increase may be attributable to true physical/biological differences (elasticity of arteries) between the races, and to a lesser extent, to differences in health behavior (Din-Dzietham et al 2004).Hispanics and blacks are more likely to report fair or poor health. Black males are more susceptible to firearm-related deaths and HIV infection. Whites have a substan-tially lower incidence of cancer than blacks in general, and a majority of this differ-ence is due to poverty-related behavior. Five-year survival rates for non-whites are much lower as well for most conditions than for whites. Overall, most of the morbidity and mortality difference between the races is due to socioeconomic status, less access to care, and behavioral factors poverty: poor people are sicker than non-poor people throughout the world. Poorer nations (developing countries) have sub-stantially higher mortality and morbidity rates than wealthier nations (developed countries). Poverty can adversely affect health by several mechanisms: inadequate physical/social environment, inadequate information and knowledge, a risk-promoting lifestyle or unhealthy attitudes and behaviors, and through diminished access to health care. The result of the combination of these factors is decreased survival rates and an increase in the incidence of diseases

Emergency care

can be provided at the scene of an accident, en route to the hospi-tal, or at the hospital emergency department. The main purpose of emergency care is to stabilize the patient until arrival at a hospital trauma center or emergency room. Emer-gency care can include transport by fixed-wing aircraft, helicopters, boats, or even snowmobiles equipped to provide emergency care such as basic and advanced life support. Emergency care providers can include physicians, nurse practitioners, nurses and emergency medical technicians (EMTs).

health disparities

differences in the incidence, prevalence, mortality, and burden of diseases and other health conditions among specific population groups The IOM model views health care disparities as resulting from characteristics of the health care system, the society's legal and regulatory climate, discrimination, bias, stereotyping and uncertainty. Not all dissimilarities in care are necessarily a disparity. -differences in treatment may be the result of patient or provider preferences, but they could indicate disparities in treatment as well. At this time, it is very difficult to determine the cause of disparities and, therefore, how to improve them.

environmental changes and reconstructuring of helathcare system

fee for service to prospective payment mainline medicine to multiple discrete subdisiplines private practice to corporate medicine direct payer to third party payer inpatient to outpatient intervention to prevention medical model to sociomedical model length of life to quality of life absolute trust in provider to trust in several or no authority confidence in institutions to no sense of obligation to institutions

health education and preventative care

focus on changing attitudes and behaviors to prevent or lessen the impact of disease. Examples of health education and prevention include immunizations, hypertension control, cholesterol control, smoking cessation, exercise, stress management, and breast cancer screening. They fall under population-based care and clinical preventive care

personal health care services

focus on the provider and patient relationship *visiting your family doctor*

four major components of health

heredity or genetics the environment lifestyle *biggest influence for improving health* the organization and delivery of health care services.

manipulative and body-based medicine

include chiropractic and massage ther-apy. Chiropractic doctors treat problems with the musculoskeletal and nervous system, largely using spinal manipulation or "chiropractic adjustment." Chiropractors may also prescribe exercises used in physical therapy or counsel patients on nutrition, diet, and exercise

biological based practices

involve the use of natural substances such as herbs, vitamins, and supplements to improve health or prevent disease. Examples include taking Ginkgo biloba to improve memory or zinc or vitamin C to prevent a cold

energy medicine

involves the use of energy (biofield therapy) and elec-tromagnetic fields (bioelectromagnetic-based therapy) to affect health. The National Center for Complementary and Alternative Medicine divides the practice of energy medicine into two categories: veritable and putative, the former confined to energy systems whose existence has been confirmed and proven by scientific investigation like electromagnetism, and the latter based on theorized energy forms for which scientific investigation has not confirmed the existence, like biofield energy

informal medicine

is practiced when family and friends influence our health and medical-seeking behavior. For example, comments such as "You don't look well. You should take some vitamin C," or "You should see a doctor" are examples of informal medicine

sickness

is relative and relates closely to social position, which includes age, occupation, marital status, and education. Therefore, any definition of illness varies with social role. According to Parsons (1951) there are four components of the sick role: *parsons sick role* 1.Individuals are not held responsible for their disease. 2.Individuals are exempt from normal social responsibilities and role obligations. 3.The state of illness is undesirable, and patients want to recover. 4.Sick people are obligated to seek help from health care experts

Health status

is the level of health of a person, group, or nation. We can measure a person's health status in many ways. -physiological measures of health such as blood pressure, white blood cell count, and temperature can be used to diagnose signs of physical illness. -Psychological measures such as the Center for Epidemiological Studies Depression Scale (CES-D) can be used to diagnose whether a person has a mental disorder, such as depression. -Humans are also very good at measuring their own level of health. Health care-related surveys often ask how respondents perceive their physical and psychological well-being. - Incidence measures the number of new cases of a disease over a period of time. Prevalence measures the number of total cases of a disease (existing and new) over a period of time. - infant mortality rate (IMR)is the rate of infant deaths (from live birth to 1 year) per 1,000 live births. -Life expectancy is the average number of years people in a given population live. - Disability-adjusted life expectancy and years of healthy life are calculated by subtracting the total number of sick and disabled days and years from the average life expectancy. -A mortality rate is one of the earliest "formal" measures of health and is still one of the most commonly used measures of health. It calculates the incidence of death per year per 1,000 or 100,000 people -Morbidity rates measure the number of people in a population who have a disease at one point in time per 100,000 people. Incidence and prevalence of diseases such as heart disease, cancer, and diabetes are often tracked over time to determine whether population health is improving or worsening. Clinical abnormalities such as high blood pressure (hypertension) and laboratory abnormalities such as hemoglobin A1C (diabetes) are measures used to diagnose morbidity. In general, the poor have higher morbidity rates than the non-poor, while women have higher morbidity (but lower mortality) rates than men, and older people higher morbidity rates than younger people. -Activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are common measures of limitations in activities. ADLsmeasure a person's ability to perform basic personal care tasks such as walking, bathing, dressing, toileting, and feeding oneself. IADLs measure ability to accomplish more independent tasks such as cleaning, shopping, managing finances, preparing meals, and using the telephone. nontraditional ways: -The medicalization of social problems significantly expands our definition of health status. Examples of measures that influence health status are juvenile violent crime arrests, single-parent families, teen suicides, births to unmarried women, number or percentage of children on welfare or in poverty, and prevalence of drug and alcohol abuse. Community health indicators include measures of infertility, proportion of the population living alone, percentage of children who are immunized, marriage and divorce rates, unemployment rates, and smoking rates (newer way) -Quality-adjusted life years are often used in cost-effectiveness calculations to determine whether a health care treatment provides a sufficient improvement in health for the amount of money that it costs. One quality-adjusted life year equals 1 year of perfect health. -Healthy life years are calculated by measuring the number of people in certain health states at each age. Measures may differ depending on what elements are included in the calculations of nonhealthy life, but generally encompass morbidities, self-rated health status, functional impairment, and limitations in activities. -compressed morbidity—that is to live a long and healthy life and then become acutely sick toward the end and die quickly

secondary care

is typically provided in community hospitals, outpatient testing centers, and specialists' offices. Some examples of secondary care include referral to specialist, surgical consults, and magnetic resonance imaging (MRI) and computerized axial tomography (CAT) scanning. Specialists include cardiologists, neurologists, radiologists, and gastroenterologists -Since secondary care is more costly than primary care, this referral hierarchy assures insurance companies that secondary care is necessary and affirms that patients need the specialist physicians' expertise

spending too little, not too much

many argue that we need to spend more money to expand access to care and develop better technology and methods for treating illness. If we spent more on health care, then we could give everyone the same level of quality of care that those with the best health insurance currently receive. Still others argue that resources that we spend elsewhere (e.g., the United Nations, aid to foreign countries, or the War on Terror) would be better spent on health care.

health care system

organization and delivery of health services -refers to a complex set of arrangements in our society that mediate between the human being and our vulnerability to disease.

primary care

referred to as "first contact" care, such as that received from the family doctor, hospital outpatient department, community health center, or university health service. It is delivered by clinicians in general practice and the medical specialties of family practice, obstetrics and gynecology, pediatrics, and general internal medicine. Primary care clinicians are generalists and treat a wide range of health care problems.

problems with our healthcare system

rising costs of health care, access barriers for the uninsured, the Medicare/Medicaid deficit, and the war against terrorism. All current problems affect access, cost, and quality and the dynamic interaction among them.

community or population-based health care

services are provided to prevent disease for large groups of people living together in a community, city, or county sanitation strategies such as developing proper sewage and waste disposal mechanisms, ensuring water quality and air quality, requiring childhood vaccinations, and offering screening programs are all community-based health care measures. Local or state public health departments provide most of these services

US spending on healthcare *prinicple problem*

the United States spends more than any other country in the world in total actual dollars ($2.49 trillion in 2009), percent of the gross domestic product (GDP; 17.6% in 2009), and per capita ($8,160 in 2009). In fact, the increase in 2009 over the previous year was the largest percent increase since 1960 (CMS 2011). At the same time, the United States is one of only two developed countries that do not have some form of universal coverage, national health insurance, or national health system. It is estimated that 50.7 million people living in the United States in 2009 did not have insurance (U.S. Census Bureau, 2010). Although our spending levels have increased over time, we have not achieved a proportional decrease in mortality or disability/restricted activity days or a propor-tional increase in life expectancy. Additionally, as costs increase, citizens demand more insurance coverage, mostly from employers. This response in turn leads to insensitivity to price on the part of consumers, higher demand for health care, and higher health care costs. *the number of uninsured is still rising in america* over 50 million in 2009

Explain how the WHO compares health care systems across countries.

the WHO used a formula comprised of many components. WHO ranked countries on the following attributes: -Health—Disability-adjusted life expectancy (DALE) and the distribution of life expectancy at birth throughout the population. WHO calculated measures such as the number of people who survived at age 1, age 2, and so on, over the entire population, how many people had each of a set of previously identified disabilities at age 1, age 2, and so on. These sets were weighted and disability was calculated by summing each of these measures with the weight. Survival at each age was then reduced by this disability figure, producing a range for the DALE and DALE distribution. According to WHO, the wider the distribution on this measure, the lower a country ranked. So if the lowest DALE and the highest DALE calculated were close together (Japan, ranked number one, was 6 years) then they were ranked higher than a country with a wider difference (the United States was 18 years) -Responsiveness—The level of responsiveness was based on "respect for the person, confidentiality, autonomy, prompt attention, proper amenities, access to social support networks, and choice of provider." Members of the WHO team surveyed almost 1,800 key informants from 35 countries and conducted an Internet survey of over 1,000 others. The distribution was also determined by key informant interviews. Most European countries, the United States, and Canada were ranked the same in distribution of responsiveness from 3-38, meaning the WHO could not distinguish between them. -Fairness in Financial Contribution—"The way health care is financed is perfectly fair if the ratio of total health contribution to total non-food spending is identical for all households, independently of their income, their health status or their use of the health system" (WHO, 2000). The description focuses on prepayment of health care rather than out-of-pocket payment, and government financing of a "progressive" system where the wealthier pay more than the nonwealthy. -Overall Goal Attainment—A measure that takes into consideration all three criteria. -Health Care Expenditure per Capita—International dollar estimate of average amount spent per person in a nation on health care. -Performance on Level of Health—A subjective ranking of a nation's "achievement relative to their resources." -Performance on Health System—Five components are weighted: 25 percent for level of health, 25 percent for distribution of health, 12.5 percent for level of responsiveness, 12.5 percent for distribution of responsiveness, and 25 percent for fairness of financial contribution

What are the social components of the health care system, and what roles do they play?

the social components of the health care system, encompasses - the organization and delivery: private physician practices, hospitals, nursing homes, and hospice and home health care agencies, -financing: determines how we pay for care. We call the organization that pays for care the "third party" in a health care transaction, because the payer is outside of the first- (patient) and second- (provider) party contract. -regulation, allocation of resources, planning, and policy, and focuses on reducing mortality and morbidity to the lowest level possible and ensuring access to high-quality care: includes such activities as state government licensure of hospitals and physicians and federal government oversight of the pharmaceutical industry, among many other examples. Most regulations involve the federal and state levels of government

goals of a health care system

the three goals of a health care system are -to treat the sick -prevent disease -set goals for maintenance and promotion of health.

what aspects are encompassed in WHO definition of health

they encompass more than just the absence of physical or mental disease but the presence of wellness. Definitions of health vary across time and cultures. Health includes the ability to contribute to society (cultural functioning) and maintain function in social roles. In addition, health reflects the ability to respond to changes in environment (physical and social) and maintain physical and psychological well-being. For example, physical relocation from one state to another or a change of jobs is often associated with anxiety, stress, and uncertainty. Healthy people adapt well to these major life changes, while others may have problems with depression or even physical illness as a result of stressful events.