US Health Systems; Ch. 1-5 Review

Why is there a geographic maldistribution of the physician labor force in the United States?

"One of the ironies of excess physician supply is that localities outside metropolitan areas (that is, counties with < 50,000 resi-dents) continue to have physician shortages." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 133

Ch. 5

Medical Technology

What is the primary reason for employers to purchase insurance plans to provide health benefits to their employees?

"... a mandate for employers to provide health insurance, which is postponed until 2015." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 8

Explain how contract practice and prepaid group practice were the prototypes of today's managed care plans.

"A common arrangement was to contract with independent physicians and hospitals at a flat fee per worker per month, referred to as capitation. The AMA recognized the neces-sity of contract practice in remote areas, but elsewhere contract practice was regarded as a form of exploitation because it was assumed that physicians would bid against each other and drive down the price. Group practice changed the relationship among physicians by bringing them together with business managers and technical assistants in a more elaborate division of labor." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 106

What are the major differences of Healthy People 2020 from the previous Healthy People initiatives?

"Healthy People 2020 is differentiated from previous Healthy People initiatives by including multiple new topic areas to its objective list, such as adolescent health, genomics, global health, health communi-cation and health information technology, and social determinants of health. Healthy People 2020 has 42 topic areas, with 13 new areas (underlined in Table 2-6)." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 71

What "preparedness"-related measures have been taken to cope with potential natural and man-made disasters since the tragic events of 9/11? Assess their effectiveness.

"Began in June 2002 - President Bush signed into law the Public Health Security and Bioterrorism Preparedness Response Act of 2002. Subsequently, the Homeland Security Act of 2002 created the Department of Homeland Security (DHS) and called for a major restructuring of the nation's resources with the primary mission of helping prevent, pro-tect against, and respond to any acts of terrorism in the United States. Now, health protection and preparedness involves a massive operation to deal with any natural or man-made threats. Includes appropriate tools and training for workers in medical care, public health, emergency care, and civil defense agencies at the federal, state, and local levels. Requires national initiatives to develop countermeasures, such as new vaccines, a robust public health infrastructure, and coordination among numerous agencies. It requires an infrastructure to handle / contain large numbers of casualties and isolation facilities for contagious patients. Hospitals, public health agencies, and civil defense must be linked together through information systems. The CDC has developed the National Biosurveillance Strategy for Human Health that most states and localities have strong biological laboratory capabilities and capacities, Strategies for expanding the surge capacity." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 52

Which conditions during the World War II period lent support to employer-based health insurance in the United States?

"Between 1916 and 1918, 16 state legisla-tures, including New York and California, attempted to enact legislation mandating employers to provide health insurance, but these efforts were unsuccessful (Davis 1996). Subsequently, three main develop-ments pushed private health insurance to become employment based in the United States: (1) To control high inflation in the economy during the World War II period, Congress imposed wage freezes. In response, many employers started offering health insurance to their workers in lieu of wage increases. (2) In 1948, the US Supreme Court ruled that employee benefits, includ-ing health insurance, were a legitimate part of union-management negotiations. Health insurance then became a permanent part of employee benefits in the postwar era (Health Insurance Association of America 1991). (3) In 1954, Congress amended the Internal Revenue Code to make employer-paid health coverage nontaxable. In economic value, employer-paid health insurance was equivalent to getting additional salary with-out having to pay taxes on it, which provided an incentive to obtain health insurance as an employer-furnished benefit. Employment-based health insurance expanded rapidly." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 99

The Blum model points to four key determinants of health. Discuss their implications for health care delivery.

"Blum proposed four major inputs that contributed to health and well-being. These main influences (called "force fields") are environment, lifestyle, heredity, and medical care, all of which must be considered simultaneously when addressing the health status of an individual or population." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 52

Provide brief descriptions of clinical information systems, administrative information systems, and decision support systems in health care delivery.

"Clinical information systems involve the organized processing, storage, and retrieval of information to sup- port patient care delivery. Ex: EMR Administrative information systems assist in carrying out financial and administrative support activities, such as payroll, patient accounting, billing, materials management, budgeting and cost control, and office automation. Decision support systems provide information and analytical tools to support managerial and clinical deci-sion making. Two types: Managerial decision support systems can be used to forecast patient vol-ume, project staffing requirements, and schedule patients to optimize uti-lization of patient care and surgical facilities. Clinical decision support systems (CDSS) encompass a range of applications, from general refer-ences, through treatment protocols, to recommendations that are tailored to a patient's unique clinical data." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 160

Why is the US health care market referred to as "imperfect"?

"Contrary to popular opinion, health care delivery in the United States is not governed by free-market principles; at best it is an imperfect market." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | page 30

Discuss the main ways in which current delivery of health care has become corporatized.

"Corporatization here refers to the ways in which health care delivery in the United States has become the domain of large organizations. These organizations have the financial resources to deliver sophisti-cated modern health care in comfortable and pleasant surroundings. But, one main expectation of maintaining quality of health care while reducing its cost remains largely unrealized. man-aged care has emerged as a dominant force by becoming the primary vehicle for insur-ing and delivering health care to the major-ity of Americans. The rise of managed care consolidated immense purchasing power on the demand side. To counteract this imbal-ance, providers began to consolidate, and larger, integrated health care organizations began forming. More recently, with the pas-sage of the ACA, many of these organiza-tions are morphing into accountable care organizations (discussed in Chapter 9). A second, influential factor behind health care integration was reimbursement cuts for inpatient acute care hospital services. As a matter of survival, many physicians consolidated into large clinics, formed strategic partnerships with hospitals, or started their own specialty hospitals. There is a growing trend of phy-sicians choosing to become employees of hospitals and other medical corporations. Corporatization has shifted marketplace power from individuals to corporations." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 108

How does technology-driven competition lead to greater levels of technology diffusion? How does technological diffusion, in turn, lead to greater competition? How does technology-driven competition lead to duplication of services?

"Despite the fact that health care delivery in the United States is not characterized by true market conditions (see Chapter 1), providers of health care services do compete. Paradoxi-cally, however, competition in health care often increases costs. Hospitals, as well as outpatient centers, compete to attract insured patients. Well insured patients look for qual-ity, and institutions create perceptions of higher quality by acquiring and advertising state-of-the-art technology. Specialists have also been responsible for stimulating com- petition. Many physicians, for example, have opened their own specialty hospitals, diag-nostic imaging facilities stocked with next-generation scanners, and same-day surgery centers that have hotel-like facilities—these developments have fueled a de facto medi-cal arms race." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 168

Why does cost containment remain an elusive goal in US health services delivery?

"Each individual and corporate entity within a predominantly private entrepreneurial system seeks to manipulate financial incentives to its own advantage, without regard to its impact on the system as a whole. Hence, cost containment remains an elusive goal." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 5

Name the four basic functional components of the US health care delivery system. What role does each play in the delivery of health care?

"Each of these basic functional components—financing, insurance, delivery, and payment—represents an amalgam of public (government) and private sources." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 4

Discuss the roles of efficacy, safety, and cost effectiveness in the context of health technology assessment.

"Efficacy or effectiveness is defined simply as health benefit derived from the use of technology. Safety considerations are designed to protect patients against unnecessary harm from technology. As a primary benchmark, ben-efits must outweigh any negative conse-quences; however, negative consequences cannot always be foreseen. Cost efficiency (or cost effectiveness) is a step beyond the determination of efficacy. Whereas efficacy is concerned only with the benefit derived from the technology, cost effectiveness evaluates the additional (marginal) benefits derived in relation to the additional (marginal) costs incurred. Technology assessment, or more specifically, health technology assessment (HTA), refers to "any process of examining and reporting properties of a medical technology used in health care, such as safety, effectiveness, feasibility, and indications for use, cost, and cost-effectiveness, as well as social, economic, and ethical consequences, whether intended or unintended" (Institute of Medicine 1985). HTA seeks to contribute to clinical decision making by providing evidence about the efficacy, safety, and cost effectiveness of medical technologies. It also informs decision makers, clinicians, patients, and the public about the ethical, legal, and social implications of medical technologies (Lehoux et al. 2009)." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Pages 180 - 182

What does the ACA propose regarding the development of biosimilars? What is this proposal intended to accomplish?

"First, the Biologics Price Competition and Innovation Act of 2009 was incorporated into the ACA. In a nutshell, the law allows the FDA to approve "biosimilars" under a process similar to the approval of generic drugs. Because of their complexity, the term "generic" cannot apply to biologics; hence, the term "biosim-ilar" was created to apply to products that are highly similar to, or are interchangeable with, an already approved biological product (referred to as the reference product). Secondly, the Biosimilar User Fee Act of 2012 authorizes the FDA to charge biophar-maceutical firms a user fee to pay for the review of applications for biosimilar prod-ucts before the products can be marketed. It is believed that the introduction of bio-similars will create competition and drive down the cost of biologics." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 174

How did the organized medical profession manage to remain free of control by business firms, insurance companies, and hospitals until the latter part of the 20th century?

"For a long time, physicians' ability to remain free of control from hospitals and insurance companies remained a prominent feature of American medicine. Hospitals and insurance companies could have hired physicians on salary to provide medical services, but individual physicians who took up practice in a corporate setting were castigated by the medical profession and pres-sured to abandon such practices. In some states, courts ruled that corporations could not employ licensed physicians without engaging in the unlicensed practice of medicine, a legal doctrine that became known as the "corporate practice doctrine" (Farmer and Douglas 2001). Independence from corporate control enhanced private entrepreneurship and put American physicians in an enviable strategic position in relation to hospitals and insurance companies. Later, a formally organized medical profession was in a much better position to resist control from outside entities." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 92

To what extent do you think the objectives set forth in Healthy People initiatives can achieve the vision of an integrated approach to health care delivery in the United States?

"For an integrated approach to become reality, resource limitations make it necessary to deploy the best American ingenuity toward health-spending reduction, elimination of wasteful care, promotion of individual respon-sibility and accountability for one's health, and improved access to basic services. An integrated approach also necessitates creation of a new model for training health care professionals by forming partnerships with the community." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | 69

In general, discuss how technological, social, and economic factors created the need for health insurance.

"From a tech-nological perspective, medicine offered new and better treatments. Because of its well established healing values, medical care had become individually and socially desir-able, which created a growing demand for medical services. From an economic per-spective, people could predict neither their future needs for medical care nor the costs, both of which had been gradually increas-ing. In short, scientific and technological advances made health care more desirable but less affordable. These developments pointed to the need for some kind of insur-ance that could spread the financial risks over a large number of people." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 97

What impact has technology had on access to medical care?

"Geography is an important factor in access to technology. If a technology is not physi-cally available to a patient population living in remote areas, access is limited. Geographic access can improve for many tech-nologies by providing mobile equipment or by employing new communications technol-ogies to allow remote access to centralized equipment and specialized personnel. Mobile equipment can be transported to rural and remote sites, making it accessible to those populations. Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 179

In the context of globalization in health services, what main economic activities are discussed in this chapter?

"Globalization refers to various forms of cross-border economic activities. It is driven by global exchange of information, produc-tion of goods and services more economi-cally in developing countries, and increased interdependence of mature and emerging world economies. Identified four different modes of economic interrelationships: (1) Advanced telecommunication infrastruc-tures in telemedicine enable cross-border transfer of information for instant answers and services. (2) Con-sumers travel abroad to receive elective, nonemergency medical care, referred to as medical tourism. (3) Foreign direct investment in health services enterprises benefits foreign citizens. (4) Health professionals move to other countries that present high demand for their services and better economic opportunities than their native countries." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 109

Why is there an imbalance between primary care and specialty care in the United States?

"Growth of new medical technology. Because the population increases at a significantly slower rate than technological advancements, the gap between primary and specialty care workforces continues to expand. Higher incomes of specialists relative to PCPs have also contributed to an oversupply of specialists. Specialists also have more predictable work hours and enjoy higher prestige among their colleagues and the public at large. The medical education environment in the United States is organized accord-ing to specialties and controlled by those who have achieved leadership positions by demonstrating their abilities in narrow sci-entific or clinical areas." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 135

What are the main provisions of HIPAA with regard to the protection of personal health information? What provisions were added to HIPAA under the HITECH Act?

"Health Insurance Portability and Accountability Act (HIPAA) of 1996 makes it illegal to gain access to a patient's personal health information (PHI) for reasons other than health care delivery, operations, and reimbursement. HIPAA legislation mandated strict controls on the transfer of personally identifiable health data between two entities, provisions for disclosure of protected infor-mation, and penalties for violation (Clayton 2001). In January 2013, the DHHS issued revisions to HIPAA in conjunction with the HITECH law. HITECH Act earmarked an estimated $19 billion in direct grants and financial incentives to promote the adoption of EHRs by hospitals and physicians (Wang et al. 2013)." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Pages 162 & 163

Generally speaking, why is medical technology more readily available and used in the United States than in other countries?

"High-tech procedures are more readily available in the United States than in most other countries, and little is done to limit the expansion of new medical technology. The United States also has more high-tech equipment, such as magnetic resonance imaging (MRI) and computed tomogra- phy (CT) scanners, available to its popu-lation than most other countries. Other nations have tried to limit, mainly through central planning, the diffusion and utilization of high-tech pro-cedures to control medical costs." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 166

What is socialized health insurance (SHI)?

"In a socialized health insurance (SHI) system, such as in Germany, government-mandated contributions by employers and employees finance health care. Private providers deliver health care services. Private not-for- profit insurance companies, called sickness funds, are responsible for collecting the contributions and paying physicians and hospitals (Santerre and Neun 1996). In a socialized health insurance system, insurance and payment functions are closely integrated, and the financing function is better coordinated with the insurance and payment functions than in the United States. Delivery is characterized by independent private arrangements.The government exercises overall control." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 20

What is the difference between national health insurance (NHI) and a national health system (NHS)?

"In a system under national health insurance (NHI), such as in Canada, the government finances health care through general taxes, but ***the actual care is delivered by private providers. In the context of the quad-function model, NHI requires a tighter consolidation of the financing, insurance, and payment functions coordinated by the government. Delivery is characterized by detached private arrangements. In a national health system (NHS), such as in Great Britain, in addition to financing a tax-supported NHI program, the government manages the infrastructure for the delivery of medical care. ***Under such a system, the government operates most of the medical institutions. Most health care providers, such as physicians, are either government employees or are tightly organized in a publicly managed infrastructure. In the context of the quad-function model, NHS requires a tighter consolidation of all four functions." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 20

Distinguish between information technology (IT) and health informatics.

"Information technology (IT) deals with the transformation of data into useful informa-tion. IT involves determining data needs, gathering appropriate data, storing and ana-lyzing the data, and reporting the information in a format desired by its end users. Health informatics is broadly defined as the application of information science to improve the efficiency, accuracy, and reliability of health care services. Health informatics requires the use of IT but goes beyond IT by emphasizing the improve-ment of health care delivery. For example, designing CDSSs falls in the domain of health informatics. Applications of infor-matics are also found in electronic health records and telemedicine." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Pages 159 & 161

Health promotion and disease prevention may require both behavioral modification and therapeutic intervention. Discuss.

"Interventions for counteracting key risk factors include two main approaches: (a) behavior modification geared toward the goal of adopting healthier lifestyles and (b) therapeutic interventions." "Various avenues can be used for motivating individuals to alter behaviors that may contribute to disease, disability, or death. Behavior can be modified through educational programs and incentives directed at specific high-risk populations." "Therapeutic interventions fall into three areas of preventive effort: primary prevention, secondary prevention, and tertiary prevention. Primary: objective is to restrain the development of a disease or negative health condition before it occurs. Secondary: refers to early detection and treatment of disease. Tertiary: refers to interventions that could prevent complications from chronic conditions and prevent further ill-ness, injury, or disability." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 46 - 47

What are some of the ethical issues surrounding the development and use of medical technology?

"MCOs, and physician advocacy institutions often act and advocate out of their own self-interests. They often claim that quality would deteriorate and/or harm would ensue unless new innovations are funded. Biases might also arise in studies funded by sources that have a financial stake in the results. Such concerns have stimulated interest in developing standards for assess-ments, perhaps under the aegis of a govern-mental body. Public and private insurers face the problem of deciding whether to cover novel treatments. The question arises as to whether society should even bear the cost of infertility treatments, genetic tests, and lifestyle remedies that do not affect people's health and longevity. Therapies classified as experimental are, generally, not covered by insurance. Availability of and payment for treatments considered experimental may be needed by critically ill patients who could possibly benefit from the treatment. that ethical clinical research must fulfill seven require-ments: (1) The research must have social or scientific value for improving health or enhancing knowledge. (2) The study must be scientifically valid and methodologically rigorous. (3) The selection of subjects in clinical trials must be fair. (4) The poten-tial benefits to patients and the knowledge gained for further scientific work must out-weigh the risks. (5) Independent review of the research methods and findings must be conducted by unaffiliated individuals. (6) Informed, voluntary consent must be obtained from subjects. (7) The privacy of enrolled subjects must be protected, they must be offered the opportunity to with-draw, and their well-being must be main-tained throughout the trial." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Pages 185 & 186

What is managed care?

"Managed care is a system of health care delivery that (1) seeks to achieve efficiencies by integrating the four functions of health care delivery discussed earlier (2) employs mechanisms to control (manage) utilization of medical services (3) determines the price at which the services are purchased and, consequently, how much the providers get paid." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 8

What role does an IT department play in a modern health care organization?

"Many health care organizations have IT departments and managers to handle the continually increasing flow of information (Tan 1995). IT departments play a critical role in decisions to adopt new information technologies to improve health care deliv-ery, increase organizational efficiency, and comply with various laws and regulations. Health care IT includes medical records systems to collect, transcribe, and store clinical data; radiology and clinical labora-tory reporting systems; pharmacy data sys-tems to monitor medication use and avoid errors, adverse reactions, and drug interac-tions; scheduling systems for patients, space (such as surgery suites), and personnel; and financial systems for billing and col-lections, materials management, and many other aspects of organizational management." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 160

Describe how health care is rationed in the market justice and social justice systems.

"Market Justice: "limitations to obtaining health care are referred to as "rationing by ability to pay" (Feldstein 1994), demand-side rationing , or price rationing. "Under social justice, the government decides how technology will be dispersed and who will be allowed access to certain types of costly high-tech services, even though basic services may be available to all. The government engages in supply-side rationing , which is also referred to as planned rationing , or nonprice rationing. In social justice systems, the government uses the term "health planning" to limit the supply of health care services, although the limited resources are often more equally dis- persed throughout the country than is gener-ally the case under a market justice system. It is because of the necessity to ration health care that citizens of a country can be given universal coverage but not universal access." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 65 - 66

What has been the main cause of the dichotomy in the way physical and mental health issues have traditionally been addressed by the health care delivery system?

"Measurement of mental health is less objective than measurement of mortal-ity and morbidity, because mental health often encompasses feelings that cannot be observed... Mental health can be assessed by the presence of certain symptoms." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 59

Who are nonphysician primary care providers? What are their roles in the delivery of health care?

"Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants. The terms nonphysician practitioners (NPPs), nonphysician clinicians (NPCs), and midlevel providers (MLPs) refer to clinical professionals who practice in many of the areas similar to those in which physi-cians practice but who do not have an MD or a DO degree. NPPs receive less advanced training than physicians but more training than RNs. They are also referred to as phy-sician extenders because in the delivery of primary care, they can, in many instances, substitute for physicians. However, they do not engage in the entire range of primary care or deal with complex cases requiring the expertise of a physician." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 141

Which particular factors that earlier may have been somewhat weak in bringing about national health insurance later led to the passage of Medicare and Medicaid?

"Often, when charity care was provided, private payers were charged more to make up the difference, a practice referred to as cost-shifting or cross-subsidization. In 1965, Congress passed the amendments to the Social Security Act and created the Medicare and Medicaid programs. Thus, for the first time in US history, the govern-ment assumed direct responsibility to pay for some of the health care on behalf of two vulnerable population groups—the elderly and the poor (Potter and Longest 1994)." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 103

On what basis were the elderly and the poor regarded as vulnerable groups for whom special government-sponsored programs needed to be created?

"On their own, most of the poor and the elderly could not afford the increasing costs of health care. Also, because the health status of these population groups was significantly worse than that of the general population, they required a higher level of health care services. The elderly, particu-larly, had higher incidence and prevalence of disease compared to younger groups. It was also estimated that less than one-half of the elderly population was covered by private health insurance. By this time, the growing elderly middle class was also becoming a politically active force Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 103

What were the two main aspects of the Supreme Court's ruling in lawsuits filed against the Affordable Care Act?

"Over one-half of the states and some private parties filed lawsuits challenging the constitutionality of the ACA. The main issue in these suits was whether the federal government had the constitutional author-ity to mandate people that they either pur-chase health insurance or pay an income tax penalty (referred to as the "individual mandate"). Federal courts in Virginia and Florida had already ruled against the law on constitutional grounds. Ruled that the majority of ACA provisions— including the individual mandate—were constitutional under Congress' power to tax. The Court, however, struck down a major provision of the law. The Court held that the federal government could not coerce states to expand their state Medicaid programs by threatening to eliminate funding." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 113

Discuss the relationship of dependency within the context of the medical profession's cultural and legitimized authority. What role did medical education reform play in galvanizing professional authority?

"Patients depend on the medical profession's judgment and assistance. First, dependency is created because society expects a sick per-son to seek medical help and try to get well. The patient is then expected to comply with medical instructions. Second, dependency is created by the profession's cultural authority because its medical judgments must be relied on to (1) legitimize a person's sick-ness; (2) exempt the individual from social role obligations, such as work or school; and (3) provide competent medical care so the person can get well and resume his or her social role obligations. Third, in conjunction with the physician's cultural authority, the need for hospital services for critical illness. The referral role (gatekeeping) of primary care physicians in managed care plans has also increased patients' dependency on primary care physicians for referral to specialized services. It was not until 1870 that medical education was reformed and licensing laws were passed in the United States." (Licensed = people were more obligated to receive care, medicine, etc. from licensed professionals.) Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 84 & 92

What are the major distinctions between primary care and specialty care?

"Primary care focuses on the person as a whole, whereas specialty care cen-ters on particular diseases or organ systems of the body. primary care is first-contact care and is regarded as the portal to the health care system. PCPs serve as gatekeepers. Primary care is longitudinal. In other words, primary care providers fol-low through the course of treatment and coordinate various activities, including initial diagnosis, treat-ment, referral, consultation, moni-toring, and follow-up. Primary care providers serve as patient advisors and advocates. Primary care students spend a significant amount of time in ambulatory care settings, familiarizing themselves with a variety of patient conditions and problems. Students in medical subspecialties spend signifi-cant time in inpatient hospitals, where they are exposed to state-of-the-art medical technology." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 130

Which factors explain why the demand for the services of a physician was inadequate in the preindustrial era? How did scientific medicine and technology change that?

"Professional services suffered from low demand in the mainly rural, preindustrial society, and much of the medical care was provided by people who were not physicians. The most competent physicians were located in more populated communities (Bordley and Harvey 1976). In the small communities of rural America, a spirit of strong self-reliance prevailed. At the close of the Civil War (1861-1865), "anyone who had the inclination to set himself up as a physician could do so, the exigencies of the market alone determining who would prove successful in the field and who would not" (Hamowy 1979). Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 87

What are the main objectives of public health?

"Public health deals with broad societal concerns about ensuring conditions that promote optimum health for the society as a whole. The vast majority of public health efforts are carried out by government agencies, such as the CDC in the United States. Public health focuses on populations (Shi and Johnson 2014). Public health focuses on (a) identifying the environmental, social, and behavioral risk factors as well as emerging or potential risks that may threaten people's health and safety, and (b) implementing pop-ulation-wide interventions to minimize those risk factors (Peters et al. 2001). (3) Medicine focuses on the treatment of dis-ease and recovery of health. Public health deals with various efforts to prevent disease and counteract threats that may negatively affect people's health. Public health activities can range from providing education on nutrition to passing laws that enhance automobile safety." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 48

Summarize the government's role in technology diffusion.

"Regulation of Drugs, Equipment / Devices, and Biologics" Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 171 - 173

Discuss the main cultural beliefs and values in American society that have influenced health care delivery and how they have shaped the health care delivery system.

"Some of the main beliefs and values prevalent in the American culture are outlined as follows: 1. A strong belief in the advancement of science and the application of sci-entific methods to medicine. 2. America has been a champion of capitalism. Due to a strong belief in capitalism, health care has largely been viewed as an economic good (or service), not as a public resource. 3. A culture of capitalism promotes entrepreneurial spirit and self-deter-mination. Hence, individual capa- bilities to obtain health services have largely determined the production and consumption of health care— which services will be produced, where and in what quantity, and who will have access to those services. 4. Principles of free enterprise and a general distrust of big government have kept the delivery of health care largely in private hands. Hence, a separation also exists between public health functions and the private practice of medicine." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 62 - 63

Discuss the relationship between technological innovation and health care expenditures.

"Technological innovations have been the single most important factor in medical cost inflation. They have accounted for about one-half of the total rise in real (after eliminating the effects of general inflation) health care spending during the past several decades (CBO 2008; Sorenson et al. 2013). The impact of technology on costs differs across technologies, in that some—such as, cancer drugs and invasive medical devices—have significant cost implications, while others are cost-neutral or cost-saving (Sorenson et al. 2013). Three main cost drivers are associated with the adoption of medical technology. First, there is the cost of acquiring the new technology and equipment. Second, spe-cially trained physicians and technicians are often needed to operate the equipment and to analyze the results, which often leads to increases in labor costs. Third, new technol-ogy may require special housing and set-ting requirements, resulting in facility costs (McGregor 1989)." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 178

What is telemedicine? How do the synchronous and asynchronous forms of telemedicine differ in their applications?

"Telemedicine, or distance medicine, employs the use of telecommunications technology for medical diagnosis and patient care when the provider and client are separated by distance. Similar to a virtual visit, it eliminates the requirement for face-to-face contact between the examining physician and the patient. Unlike virtual visits, however, telemedicine has applications in the delivery of specialized medical services. Examples include teleradiology, the transmission of radiographic images and scans; telepathology, the viewing of tissue specimens via video-microscopy; telesurgery, controlling robots from a distance to perform surgical procedures; and clinical consultation provided by a wide range of specialists. Synchronous technology allows telecommunication to occur in real time. Asynchronous technology employs store-and-forward technology that allows users to review the information later." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Pages 164 & 165

What factors are associated with the development of health services professionals in the United States?

"The expansion of the number and types of health services professionals closely follows population trends, advances in research and technology, disease and illness trends, and changes in health care financ-ing and delivery of services. New and com- plex medical techniques, equipment, and advanced computer-based information systems are constantly introduced, and health services professionals must continually learn how to use these innovations. Special-ization in medicine has contributed to the proliferation of different types of medical technicians. The changing patterns of dis-ease, from acute to chronic, and a greater emphasis on prevention create a greater need for professionals who are formally trained to address the consequences of behavioral risk factors and the delivery of primary care. Increased insurance coverage under the Affordable Care Act (ACA) will also increase the demand for health services professionals." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 124

What main roles does the government play in the US health services system?

"The federal and state governments play an important role in health care delivery. They determine public-sector expenditures and reimbursement rates for services provided to Medicare, Medicaid, and CHIP beneficiaries. The government also formulates standards of participation through health policy and regulation, meaning providers must comply with the standards established by the government to be certified." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 10

Who are the major players in the US health services system? What are the positive and negative effects of the often conflicting self-interests of these players?

"The key players in the system have been physicians, administrators of health service institutions, insurance companies, large employers, and the government. Big business, labor, insurance companies, physicians, and hospitals make up the powerful and politically active special interest groups represented before lawmakers by high- priced lobbyists. Each set of players has its own economic interests to protect." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 15

Which factors have been responsible for the low diffusion and low use of telemedicine?

"The largest barrier to telemedicine adoption is the lack of a reimbursement model. 2010). Also, the cost effectiveness of most telemedicine applications remains unsubstantiated." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Pages 165 & 166

Provide a general overview of the Affordable Care Act. What is its main goal?

"The main goal of the ACA is to increase access to health care and make it more affordable, mainly for those who were previously uninsured." "rolled out gradually starting in 2010 when insurance companies were mandated to start covering children and young adults below the age of 26..... mandate for employers to provide health insurance, which is postponed until 2015....requires that all US citizens and legal residents must be covered by either public or private insurance. The law also relaxed standards to qualify additional numbers of people for Medicaid.... Federal subsidies have been made available to people with incomes up to 400% of the federal poverty level to partially offset the cost of health insurance....The law mandates insurance plans to cover a variety of services referred to as "essential health benefits."...by its own design, the ACA would fail to achieve universal cover-age that would enable all citizens and legal residents to have health insurance." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Pages 8 & 31

Discuss the definitions of health presented in this chapter in terms of their implications for the health care delivery system.

"The medical model defines health as the absence of illness or disease... Medical sociologists have gone a step further in defining health as the state of opti-mum capacity of an individual to perform his or her expected social roles and tasks, such as work, school, and doing household chores (Parsons 1972). A person who is unable (as opposed to unwilling) to perform his or her social roles in society is consid-ered sick... the definition of health proposed by the Society for Academic Emergency Medicine, accord-ing to which health is "a state of physical and mental well-being that facilitates the achievement of individual and societal goals"... WHO defines health as "a state of complete physi-cal, mental and social well-being and not merely the absence of disease or infirmity" (WHO 1948). As a biopsychosocial model, WHO's definition specifically identifies social well-being as a third dimension of health... Holistic health incorporates the spiri-tual dimension as a fourth element—in addition to the physical, mental, and social aspects—necessary for optimal health." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 41

In general, who are allied health professionals? What role do they play in the delivery of health services?

"The term allied health is used loosely to categorize several different types of profes-sionals in a vast number of health-related technical areas. Among these professionals are technicians, assistants, therapists, and technologists. These professionals receive specialized training, and their clinical inter-ventions complement the work of physi-cians and nurses. Certain professionals, however, are allowed to practice indepen-dently, depending on state law." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 142 - 143

Discuss the significance of an individual's quality of life from the health care delivery perspective.

"The term quality of life is used to capture the essence of overall satisfaction with life during and following a person's encounter with the health care delivery system. It is an indicator of how satisfied a person is with the experiences while receiving health care. These factors are now regarded as rights that patients can demand during any type of health care encounter. It also can refer to a person's overall satis-action with life and with self-perceptions of health, particularly after some medical intervention." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 43

Discuss the intermediary role of insurance in the delivery of health care.

"Third-party insurers act as intermediaries between the financing and delivery functions." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | page 9 "Most patients, however, are now enrolled in either a private health plan or government-sponsored program(s). These plans act as intermediaries for the patients, and the consolidation of patients into health plans has the effect of shifting the power from the patients to the administrators of the plans." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | page 12 "Insurance often functions as the intermediary among those who finance, deliver, and receive health care. The insurance intermediary does not have the incentive to be the patient's advocate on either price or quality." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | page 14

Provide a brief description of the roles and responsibilities of health services administrators.

"Top-level administrators provide leadership and strategic direction, work closely with the governing boards, and are responsible for an organization's long-term success. They are responsible for operational, clinical, and financial outcomes of their entire organization. Middle-level administrators may have leadership roles for major service centers, such as outpatient, sur-gical, and nursing services, or they may be departmental managers in charge of single departments, such as diagnostics, dietary, rehabilitation, social services, environmen-tal services, or medical records. Their jobs involve major planning and coordinating functions, organizing human and physical resources, directing and supervising, opera-tional and financial controls, and decision making. They often have direct responsibility for implementing changes, creating effi-ciencies, and developing new procedures with respect to changes in the health care delivery system. Entry-level administrators may function as assistants to middle-level managers. They may supervise a small num- ber of operatives. For example, their main function may be to oversee and assist with operations critical to the efficient operation of a departmental unit." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 146

Provide a brief overview of how technology influences the quality of medical care and quality of life.

"When advanced techniques can provide more precise medical diagnoses than before, quicker and more complete cures than pre-viously available, or reduce risks in a cost-effective manner, the result is improved quality. Technology can also provide new remedies where none existed before. More effective, less invasive, and safer therapeutic and preventive remedies can increase longevity and decrease morbidity." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 176

Why did medicine have a domestic, rather than professional, character in the preindus-trial era? How did urbanization change that?

"While London, Paris, and Berlin were flourishing as major research centers, Americans had a tendency to neglect research in basic sciences and to place more emphasis on applied science (Shryock 1966). In addition, American attitudes about medical treatment placed strong emphasis on natural history and con-servative common sense (Stevens 1971). Consequently, the practice of medicine in the United States had a strong domestic, rather than professional, character. iRapid urbanization was another factor that necessitated the institutionalization of medical care. As had already occurred in Europe, in the United States, hospitals became the core around which the delivery of medical services was organized. Thus, development of hospitals as the center for the practice of scientific medicine and the professionalization of medical practice became closely intertwined." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 85

How did the emergence of general hospitals strengthen the professional sovereignty of physicians?

"hospitals became the core around which the delivery of medical services was organized. Thus, development of hospitals as the center for the practice of scientific medicine and the professional-ization of medical practice became closely intertwined." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 91

Why is it important to achieve a balance between clinical efficacy and economic worth (cost effectiveness) of medical treatments?

Achieving a balance between efficacy and economic worth will require a change in the American mindset, which will not be forth-coming in the near future. "In the United States, the predominant fear is that an orga-nization risks being sued if it denies access to treatments that are known to be medically effective even when their cost effectiveness is questionable (Bryan et al. 2009). With-out malpractice reform, overuse of technol-ogy will continue to rack up costs. At some point, the United States may have no choice but to restrict the use of medical technolo-gies on the basis of their economic worth." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Pages 184 & 185

Ch. 1

Basic Components of a Health Care Delivery System

Ch. 4

Health Service Professionals

What measures have been or can be employed to overcome problems related to physician maldistribution and imbalance?

In recent years, reimburse-ment systems designed to increase payments to PCPs have been implemented, but wide disparities between the incomes of gener-alists and specialists continue Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 134

Discuss, with particular reference to the roles of (a) organized medicine (b) the middle class (c) American beliefs and values, why reform efforts to bring in national health insurance have historically been unsuccessful in the United States.

Matters related to health and welfare were typically left to state and local governments, and as a general rule, these levels of government left as much as possible to pri-vate and voluntary action. Also in 1920, the AMA's House of Delegates approved a resolution condemn-ing compulsory health insurance that would be regulated by the government (Numbers 1985). The main aim of this resolution was to solidify the medical profession against government interference. Dominance of private institutions of health care delivery was seen to be incon-sistent with national financing and payment mechanisms. The insurance industry feared losing the income it derived from disability insurance, some insurance against medical services, and funeral benefits* (Anderson 1990). The pharmaceutical industry feared the government as a monopoly buyer, and retail pharmacists feared that hospi-tals would establish their own pharmacies under a government-run national health. Union leaders were afraid they would transfer over to the government their own legitimate role of providing social benefits, thus weaken-ing the unions' influence in the workplace. Organized labor was the largest and most powerful interest group at that time, and its lack of support is considered instrumental in the defeat of national health insurance (Anderson 1990). The American value system has been based largely on the principles of market justice. when a government- controlled medical plan was compared to pri-vate insurance, polls showed that only 12% of the public favored extending Social Security to include health insurance (Numbers 1985). During this era of the Cold War,* any attempts to introduce national health insur-ance were met with the stigmatizing label of socialized medicine, a label that has since become synonymous with any large-scale government-sponsored expansion of health insurance or intrusion in the private practice of medicine. National health care program might be ripe. Wof-ford's call for national health insurance was widely supported by middle-class Pennsyl-vanians. Election results in other states were not quite as decisive... avoiding tax increases took priority over expanding health insurance coverage and caused the demise of Clinton's health care reform initiatives." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Pages 100 - 104

Describe the major types of health services professionals (physicians, nurses, dentists, pharmacists, physician assistants, nurse practitioners, certified nurse midwives), in-cluding their roles, training, practice requirements, and practice settings.

Physicians Nurses Dentists Pharmacists Physician Assistants Nurse Practitioners Certified Nurse Midwives

How can health care administrators and policymakers use the various measures of health status and service utilization? Please illustrate your answer.

Statistics, measurements, self perceived or calculated health status, utilization of services

3

The Evolution of Health Services in the United States

Briefly describe the concepts of market justice and social justice. In what way do the two principles complement each other and in what way are they in conflict in the US system of health care delivery?

The two contrasting principles complement each other with employer-based health insurance for most middle-class working Americans (market justice) and publicly financed Medicare, Medicaid, and CHIP coverage for certain disadvantaged groups (social justice). Market and social justice principles cre-ate conflicts when health care resources are not uniformly distributed throughout the United States, and there is a general short-age of primary care physicians (discussed in Chapter 4). Consequently, in spite of having public insurance, many Medicaid-covered patients have difficulty obtaining timely access, particularly in rural and inner-city areas. In part, this conflict is created by artificially low reimbursement from public pro-grams whereas reimbursement from private payers is more generous. Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 67

According to the Institute of Medicine, what are the four main components of a fully developed electronic health record (EHR) system?

"(1) Collection and storage of health information on indi-vidual patients over time; (2) immediate electronic access to person- and population-level information by authorized users; (3) availability of knowledge and decision support that enhances the quality, safety, and efficiency of patient care; (4) support of efficient processes for health care delivery." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 161

What is the role of health risk appraisal in health promotion and disease prevention?

"A program of health promotion and disease prevention is built on three main principles: (1) An understanding of risk factors associated with host, agent, and/or environment. Risk factors and their health consequences are evaluated through a process called health risk appraisal. Only when the risk factors and their health consequences are known can interventions be developed to help individuals adopt healthier lifestyles." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 46

What are the two main objectives of a health care delivery system?

"An acceptable health care delivery system should have two primary objectives: (1) it must enable all citizens to obtain needed health care services (2) the ser-vices must be cost effective and meet cer-tain established standards of quality." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | page 5

Why is it important for health care managers and policy makers to understand the intricacies of the health care delivery system?

"An understanding of the health care deliv-ery system can attune health profession-als to their relationship with the rest of the health care environment. It can help them understand changes and the impact of those changes on their own practice. Adaptation and relearning are strategies that can prepare health professionals to cope with an environment that will see ongoing change long into the future." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Page 18

Medical technology encompasses more than just sophisticated equipment. Discuss.

"At a fundamental level, medical technology is the practical application of the scientific body of knowledge for the purpose of improving health and creating efficiencies in the delivery of health care." Copyright | Jones & Bartlett Learning | Delivering Health Care in America | Edition 6 | Page 159