HCA 701: Survey of the U.S.
Healthcare System
Introduction to Healthcare Services in
the United States
RESOURCES NEEDED TO MAINTAIN A
HEALTH CARE DELIVERY SYSTEM
Financing
Healthcare
Professionals
Health Care
Delivery
System
Facilities
Technology &
Supplies
Source: Williams and Torrens,
Introduction to Health Services, 2002
BASIC SERVICE COMPONENTS OF A
HEALTH CARE SYSTEM

Public Health (Including Health Promotion and Disease
Prevention)
 Emergency medical services (including transportation)
 Ambulatory care for simple/limited conditions
 Acute and community hospitals and medical centers
 Long-term care (either in-home or institutional care)
 Mental Health Services (both inpatient and ambulatory)
 Rehabilitation services (both inpatient and ambulatory)
 Dental services
 Pharmaceuticals/supplies/medical devices and
equipment
Brief History of the Development of the U.S.
Health Care System 1850 – World War II
1850 – 1900
1900 – WWII
Major targets at the
time
Epidemics of acute infections
related to food, water, housing
and other conditions of life
Acute events, trauma, or
infections affecting individuals
not groups
Technology available
Virtually none
Beginning of rapid growth of
basic medical sciences &
tech
Social Organization for
health care
None; individuals left to their
own resources or charity
Societal/governmental efforts
begin to care for those who
can’t care for themselves
Involvement of people
in their health care
People actively involved in
giving care to family; little
factual knowledge
Medical knowledge begins to
take shape in general public
Issues
Brief History of the Development of the
U.S. Health Care System WWII - Present
Issues
WW II – 1980
1980 - Present
Major targets at the
time
Chronic diseases such as
heart disease, cancer,
stroke
Greater emphasis on chronic diseases,
emotional/behavioral issues,
occupational and genetic inheritance
Technology available
Explosive growth in medical
science; technological
takeover
Continued advancement in technology
contributing to rapid rise in health care
costs
Social Organization
for health care
Health insurance becomes
primary vehicle for
organization of health care
Increasing power of financial
organizations; increasing influence of
governmental financial systems
(Medicare, Medicaid).
Involvement of people
in their health care
Health care becomes social
and political issue
Well-informed public but confusing
complexity of system
Life Expectancy at Birth
Life Expectancy at Birth and at age 65 years 1900, 1950, and 2000
Classification for Health Status
Today

Disease – a state of dysfunction of the normal
physiological processes manifested as signs,
symptoms, and abnormal physical or social function
(includes injury).

Functional Ability – a process used to represent how
independently an individual can perform or fulfill
expected social roles (physical and mental).

Quality of Life – multidimensional concepts of
measures covering symptoms/problem complexes,
mobility, physical activity, emotional well-being and
social functioning.
Blum’s Model of Factors Affecting
Health
Health
Environment
Lifestyle
•Fetal
•Attitudes
•Prevention
•Physical
•Behavior
•Cure
•Socio/Cultural
Biology
Medical Care
•Care
•Rehabilitative
Primary Cause of Death 1997
Source: Healthy People 2010
Healthcare Professionals

Healthcare is a major employer
 It has a rapidly growing labor sector




Professionals
Non-professionals and technicians
Non-institutional workers
Rapid growth due to:




Technology growth and specialization
Health insurance coverage
Aging population
Emergence of hospitals
Types of Healthcare Worker
Certification
Licensure – state or legal designation
 Certification and registration
 Independent and dependent professions

Independents practice without physician
supervision (e.g., doctors, dentists)
 Dependents need physician supervision
(most nurses, CNAs)

Physicians

Comprised of two types by practice

Primary care physicians – short supply in
U.S.


Family Practice, Internal medicine, OB/GYN,
Pediatricians
Specialists – Surplus in U.S.

Specialize in specific areas
Physician Surplus or Shortage?

Rapid growth of physicians, esp. specialists,
during 1980-95 due to:



Maldistribution of physicians can give
appearance of shortage



Massive federal outlays
Influx of International Medical Graduates (IMGs)
Not enough primary care providers
Medical underserved areas in rural communities
and inner cities
Malpractice and the impact on physicians
Changing Role of the Physician

More employed physicians

By managed care organizations and
hospitals (the emergence of the
“Hospitalist”)
Large group practices emerged with the
growth of managed care
 Emphasis away from specialty areas to
managed care
 More female physicians

Distribution of Physicians by Specialty:
1980, 1986, 1995, 2000 (In thousands
Specialty
All specialties
1980
No./%
414/100
1986
1995
No./%
No./%
521/100 630/100
2000
No./%
684/100
Pct. Change
1986-2000
31.4
Primary Care
159/38.5
179/34.4
205/32.5
219/32.0
22.2
Other Medical
Specialties
25/6.2
62/12.0
83/13.2
94/13.7
50.2
Surgical Specialties 110/26.7
134/25.7
158/25.2
170/24.9
27.0
All other specialties 118/28.5
144/27.8
183/29.1
201/29.4
38.9
Will doctors meet demand in a bioterror event
Nurses
Typifies the concern of healthcare: “nursing is
concerned with human response to health
problems”
 Historic factors that shaped nursing as a
career:





Occupation to support physicians
Emergence of hospitals as community institutions
Acceptable female occupations, primarily white
females
Linked to religious orders
Understanding the Nursing Shortage






Changes in occupational opportunities for
women since 1970s
Majority of RNs are 50+ years of age or
married with children at home
Low salaries – pay compression
Burnout
Lack of clinical career ladder
Active vs. Inactive – about 1/3 of nurses not
working fulltime
Ambulatory Care

Personal health care given to the patient in an
non-hospital or institutional setting
 Types of settings:





Physician owned private practice
Managed care clinic settings
Community health care settings
“Urgent care” facilities
Shift to ambulatory care due to several factors:



Medicare PPS
Managed care
Improved technology
Patient Visits per 100 persons by Ambulatory
Service Type, 1993-94 and 1999-2000
180
160
140
120
100
80
1993-94
1999-2000
60
40
20
0
Primary Care
Visit
Surgical
Specialty
Medical
Specialty
Practice
Outpatient
Dept.
Emergency
Dept.
Hospitals

The growth of Hospitals in the U.S. is a fairly recent
history:






Hill-Burton
Hospital Insurance
Advances in medical science
Professional nursing
Improved medical school training for physicians
Cost containment practices have lowered hospital
utilization



Decreased inpatient utilization through DRGs and managed
care
Shift to outpatient services
System and specialty hospital growth
Hospital Classification
For-profits – fastest growing type of hospitals
 For-profit and non-profit systems (e.g., Kaiser
Permanente, Catholic Hospitals West)
 Public Hospitals





Numbers are in decline
Serve disproportionate number of Medicaid and
uninsured
Account for nearly 25% of uncompensated care
Includes federally funded facilities such as VA and
Armed Services facilities (McCallahan Federal
Hospital)
Hospitals (types cont.)

Academic teaching hospitals



Tripartite mission
Face shaky future
Rural Hospitals





Small, non-profit
Many with nursing home swing beds
Endangered
Quality of care in question
Types of services available being lost to cities
Number of Public Community
Hospitals, U.S.
1,600
1,400
1,200
1,000
800
600
400
200
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 200 2001 2002
Constraining and Propelling Forces
Affecting Hospital
Constraining
 Governmental and third party
purchaser pressure for cost
containment
 Competition from multihospital systems and local
physicians
 Conservatism of some
traditionally oriented
practicing physicians
 Cost of continuing
technological advances
 Slower growth of the
economy
 Changing governmental
philosophy toward health
care
Propelling
 New health markets other
than inpatient care
 Weakening power of
physicians in the hospital
 New organizational structures
 Increasing power of a more
business-oriented
management team
 Aging of the population
 Changing customer
expectations for service
Hospital Beds per 1,000 population
by Ownership, 2002
Nevada
U.S.
State/Local
Government
Hospital Beds
17%
16%
Non-Profit
Hospital Beds
32%
71%
For Profit
Hospital Beds
51%
13%
Background: Las Vegas Hospitals
September, 2001
Total
Govt.
(n=2)
Private,
For-Profit
(n=6)
Private,
Non-Profit
(n=3)
Number of Hospital
Beds
2972
639
1963
370
Number of ER Beds
272
61
161
50
Isolation Beds
166
46
58
62
ER Clinicians
379
95
240
44
Security Staff
136
49
67
20
Decontamination Capabilities and
Personal Protection Equipment, 2001
10
9
8
7
6
5
4
Yes
No
3
2
1
0
Fixed
Attached
Showers
Portable
Showers
M ultiple
Staff
ER Staff
Other
Full-Face Non-Encap.
Shower Training for can Perform Breathing Air Purifier Chemical
Capability
Decon.
Triage in Apparatus
M ask
Resistant
PPE
Suit
Hospitals and Emergency Preparedness:
Observation Areas and Data Collection
12
10
8
6
4
2
0
Yes
No
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Mental Health Services
Definition: Painful emotional symptoms…inability
to think, remember or concentrate…increased
potential of medical illness, pain, disability or
even death
 Affects 30% of all adults
 Most mental illness is untreated
 20-40% of homeless population is suffers from
mental illness
 Mental illness is a crisis situation for Nevada
hospitals
Percent Distribution of Mental Health 24-hour
hospital and residential treatment beds
90
80
70
State and county
Private Psychiatric
Non-federal general
VA Med Centers
RTCs
All Others
60
50
40
30
20
10
0
1970
1976 1980
1986
1990 1994
1998
Who Gets Treatment for Mental
Illness?
65%
20%
7%
8%
Mental or Addictive illness
receiving treatment
No defined illness,
received treatment
Mental or addictive
illness, not treatment
No defined illness, no
treatment