Essentials of the U.S. health care system

Description

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