The US Healthcare System

1
The US Healthcare System

• Impact on Equity, Efficiency and Effectiveness

2
Need vs. Demand and Utilization

• Need an interpretation of an individuals
  evaluated requirements for obtaining professional
  care through the health service system
• Demand seeking out, but not necessarily
  receiving health services.
• Utilization actual use of services. A result of
  need and demand

3
Health Care Spending in the U.S.

• In 2003, 1.7 trillion was spent on health care
  in U.S.
• In 2003, the United States spent 15.3 percent of
  its Gross Domestic Product (GDP) on health care.
  Compared to other countries
• Switzerland 10.9
• Germany 10.7
• Canada 9.7
• France 9.5
• 45 million Americans were uninsured in 2003
• Total out-of-pocket spending on health care rose
  13.7 billion, to 230 billion in 2003.

4
Spending by Service in Health Care 2002
Service Amount Spent 2002 (in billions) Major cost factors
Hospitals 486.5 (9.5 increase) Inflation increase in patient volume
Physicians 339.5 (7.7 increase) Medicare costs decelerated causing a reduction in the rate of growth in physicians spending
Drugs 162.4 billion (15.4 increase) Rate decelerated from 2001. Out of pocket expenses increased.
5
Percent of health care expenditures 2002
6
Four Systems of Health Care

• Private, insured, middle-income Americans
• Poor, unemployed or under-employed Americans
• Active duty military personnel
• Veterans of military service

7
Private, insured, middle-income Americans

• Care is coordinated by physicians in private
  practice
• Care is funded by insurance (personal,
  non-governmental sources paid for by employer,
  individual or both)
• Characterized as an informal system of care
• Even though it is an informal system, patient has
  considerable control over their care
• It is also often poorly coordinated
• Medicare for the middle-income

8
Poor, Unemployed/Underemployed Families Without
Insurance

• No formal system
• Majority of services are provided by local
  government agencies
• Patients have no continuity of service
• Poor must take whatever they can get
• Use of Medicaid other government funded services

9
Military Medical System

• A well-organized system of high quality care at
  no direct cost to the recipient
• All inclusive and omnipresent
• System in effect whether personnel want it or not
• Emphasis is on keeping personnel well, prevention
  and early treatment of injury or illness
• It is a closely organized, highly integrated,
  rational and regionalized approach

10
Veterans Administration Health Care System

• Provides care to retired, disabled or other
  deserving veterans of military service
• History of VA is rooted in controversy
• Not as complete as other services
• Large number of male patients
• VA health system is just one of a system of
  social services and benefits for veterans
• Interest group representation
• 1990s represented a waning period for veterans
  and veteran services (Snowbirds)
• Future for the veteran

11
Brief History of Public Health

• Hippocrates and the Greeks
• The Middle Ages and the decline of public health
• The Renaissance and the re-emergence of lost
  knowledge
• The Enlightenment demonstrates the importance of
  a healthy population
• The Sanitary movement shows the importance of
  science and medicine
• The age of bacteria leads to vector control

12
Brief History of Public HealthModern Times

• WWI introduced poison gas as warfare
• Draining of swamps reduces mosquito borne disease
• In 1919, Spanish Flu pandemic killed 30 million
  world-wide
• Fleming discovers penicillin in 1928
• In WWII, protecting soldiers from disease leads
  to more death from injuries and wounds than from
  infection for the first time in history of wars
• The World Health Organization was formed in 1948
• Salk invents the polio vaccine
• In 1978, smallpox is eradicated from the planet
• In 1979, the first cases of AIDS appear
• In 1980s, poison gas once again used in warfare
  (Iran-Iraq war)
• New diseases emerge AIDS, SARS, drug-resistant
  staphylococcus

13
Public Health Priorities for the Future

• Continue the pursuit of the eradication of
  disease and its causes
• Getting the public to understand that preventing
  disease does not rely solely on new medicine or
  inventions
• Making sure that we dont undo the advances that
  we have already made

14
Blums Model of Factors Affecting Health
Health

• Environment
• Fetal
• Physical
• Socio/Cultural

• Lifestyle
• Attitudes
• Behavior

Biology

• Medical Care
• Prevention
• Cure
• Care
• Rehabilitative

15
Infectious and Chronic Disease
16
Primary Cause of Death 1900
17
Primary Cause of Death 1997Source Healthy
People 2010
18
Population characteristics and the use of
healthcare service

• Person Measures
• Age
• Sex
• Ethnic group and race
• Social class/social-economic status

19
Prevention and Health Promotion

• Primary inhibition of the development of the
  disease before it occurs
• Secondary early detection and treatment of a
  disease
• Tertiary the rehabilitation or restoration of
  effective functioning

20
Implications of an Aging Population
Source Williams and Torrens, 2002
21
Comparing U.S. with Other Countries
22
Selected Cause of Death 1950-98
23
Suicide Rate by Age, Sex and Race per 100,000
24
Firearm Related deaths per 100,000 in U.S.
Source Williams and Torrens, 2002
25
Years of Productive Life Lost before Age 65 among
Children less than 20 Years
26
Relating Population Characteristics to Health
System Characteristics

• Organization to examine over- or
  under-utilization
• Personnel the number of staff, their
  qualifications, and other manpower needs.
• Technology which devices, procedures,
  pharmaceuticals are effective and efficient
• Programmatic efforts examining the quality of
  services provided

27
Patient Visits per 100 persons by Ambulatory
Service Type, 1993-94 and 1999-2000
28
Blums Model of Factors Affecting Health
Health

• Environment
• Fetal
• Physical
• Socio/Cultural

• Lifestyle
• Attitudes
• Behavior

Biology

• Medical Care
• Prevention
• Cure
• Care
• Rehabilitative

29
Primary Cause of Death 1997Source Healthy
People 2010
30
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

31
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)

32
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

33
Physician Surplus or Shortage?

• Rapid growth of physicians, esp. specialists,
  during 1980-95 due to
• Massive federal outlays
• Influx of International Medical Graduates (IMGs)
• Maldistribution of physicians can give appearance
  of shortage
• Not enough primary care providers
• Medical underserved areas in rural communities
  and inner cities
• Malpractice and the impact on physicians

34
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

35
Distribution of Physicians by Specialty 1980,
1986, 1995, 2000 (In thousands

• 1980 1986 1995 2000 Pct.
  Change
• Specialty No./ No./ No./
  No./ 1986-2000
• All specialties 414/100 521/100 630/100
  684/100 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

36
Will doctors meet demand in a bio-terror event
37
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

38
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

39
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

40
Patient Visits per 100 persons by Ambulatory
Service Type, 1993-94 and 1999-2000
41
Physician Authority

• Based on modern science and scientific knowledge.
• Physicians become the intermediaries between
  science and private experience
• Authority signifies the presence of status and
  quality
• Requires legitimacy and dependence.
• Legitimacy acceptance by subordinates
• Dependence bad things can happen if we dont
  obey
• Types of Physician Authority
• Social Authority
• Cultural Authority
• Professional Authority

42
The Evolution of the Physician in the U.S.

• Allopathic
• Homeopathy
• Osteopathic
• Chiropractic

43
(No Transcript)
44
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

45
Physician Surplus or Shortage?

• Rapid growth of physicians, esp. specialists,
  during 1980-95 due to
• Massive federal outlays
• Influx of International Medical Graduates (IMGs)
• Distribution of physicians gives appearance of
  shortage
• Not enough primary care providers
• Medical underserved areas in rural communities
  and inner cities
• Malpractice and the impact on physicians

46
Physicians NV vs. US
Physicians Type Nevada U.S.
Physician generalists per 100,000 population 21 30
Physician specialists per 100,000 142 206
47
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

48
Physicians who would recommend the practice of
medicine
49
For physicians who wouldnt recommend medical
profession
50
Distribution of Physicians by Specialty 1980,
1986, 1995, 2000 (In thousands

• 1980 1986 1995 2000 Pct.
  Change
• Specialty No./ No./ No./
  No./ 1986-2000
• All specialties 414/100 521/100 630/100
  684/100 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

51
Physician Medical Education

• Undergraduate medical curriculum
• Most emphasize the acute care setting
• Increase in women and minorities
• Graduate medical education
• Major increases in residencies
• Shifts in the organization of medical schools
• Must compete for patients
• Shift to managed care by med school hospitals
• Trends medical education in for-profit hospitals
• Flexnor Report

52
Patient Visits per 100 persons by Ambulatory
Service Type, 1993-94 and 1999-2000
53
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

54
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)

55
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

56
Number of Public Community Hospitals, U.S.
57
Constraining and Propelling Forces Affecting
Hospital

• Constraining
• Governmental and third party purchaser pressure
  for cost containment
• Competition from multi-hospital 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

58
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
59
Background Las Vegas Hospitals September, 2001
Total Govt. (n2) Private, For-Profit (n6) Private, Non-Profit (n3)
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
60
Decontamination Capabilities and Personal
Protection Equipment, 2001
61
Hospitals and Emergency Preparedness Observation
Areas and Data Collection

62
Mental Health Services

• Definition Painful emotional symptomsinability
  to think, remember or concentrateincreased
  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

63
Percent Distribution of Mental Health 24-hour
hospital and residential treatment beds
64
Who Gets Treatment for Mental Illness?