Provides a diverse, multi-faceted approach to health care evaluation and management
The U.S. Health Care System: Origins, Organization and Opportunities provides a comprehensive introduction and resource for understanding healthcare management in the United States. It brings together the many “moving parts” of this large and varied system to provide both a bird’s-eye view as well as relevant details of the complex mechanisms at work. By focusing on stakeholders and their interests, this book analyzes the value propositions of the buyers and sellers of healthcare products and services along with the interests of patients.
The book begins with a presentation of frameworks for understanding the structure of the healthcare system and its dynamic stakeholder inter-relationships. The chapters that follow each begin with their social and historical origins, so the reader can fully appreciate how that area evolved. The next sections on each topic describe the current environment and opportunities for improvement.
Throughout, the learning objectives focus on three areas: frameworks for understanding issues, essential factual knowledge, and resources to keep the reader keep up to date.
Healthcare is a rapidly evolving field, due to the regulatory and business environments as well as the advance of science. This website also offers a weekday blog of important/interesting news and teaching notes/class discussion suggestions for instructors who use the book as a text.
The U.S. Health Care System: Origins, Organization and Opportunities is an ideal textbook for healthcare courses in MBA, MPH, MHA, and public policy/administration programs. In piloting the content, over the past several years the author has successfully used drafts of chapters in his Healthcare Systems course for MBA and MPH students at Northwestern University. The book is also useful for novice or seasoned suppliers, payers and providers who work across the healthcare field and want a wider or deeper understanding of the entire system.
Table of Contents
List of Exhibits xiii
Foreword xxi
Acknowledgments xxiii
One: Understanding and Managing Complex Healthcare Systems 1
Definitions 2
Health System Structure and Features 7
Who Pays? 8
How Much Is Paid? 11
Who and What Is Covered? 12
Where Is Care Provided? 13
Who Provides the Services and Products? 14
Strategic Planning 17
Stakeholders 17
Health System Trade-offs and Value Propositions 20
Putting It All Together 30
Summary 32
Two: Determinants of Utilization of Healthcare Services 33
Reasons Stakeholders Seek Healthcare 34
Patient Characteristics That Influence Care-Seeking 36
Age 37
Gender/Sex 37
Race 39
Income 41
Social Status 42
Education 43
Culture and Beliefs 44
Multifactorial Causes 46
Reducing Patient Demand for Healthcare 47
Increase Out-of-Pocket Expenses 47
Prevention 51
Eliminate/Reduce Risky Behaviors 51
End-of-Life Issues 52
Healthy Lifestyle Promotion 54
Consumer Behavior - Healthcare Market Segmentation 54
Provider-Induced Demand for Healthcare 56
Local (Small Area) Variations 61
Summary 63
Three: Managerial Epidemiology 65
Introduction 66
What Is Epidemiology? 66
Why Is It Important to Learn about Epidemiology? 66
Definitions and Uses of Principles 67
Morbidity and Mortality 67
Incidence and Prevalence 67
Validity 67
Reliability 68
Sensitivity, Specificity, Positive Predictive Value, and Negative Predictive Value 68
Clinical Study Designs 70
Case Control Studies 70
Problems with Observational Research 72
Benefits to Employing Observational Research 73
Cohort Study 74
Randomized Controlled Trial 78
Summary 80
Four: Hospitals and Healthcare Systems 81
A Brief History of Western Hospitals 82
American Hospital Expansion in the 20th Century 88
Hospital Definition and Classifications 94
Definition 94
Ways Hospitals May Be Classified and Special Related Issues 96
Hospital Inpatient Payment Methods 137
Organized (Integrated) Delivery Systems/Accountable Care Organizations 139
Origins and Definition 139
Eligibility 143
Financial Arrangements 143
Hospital Governance 153
Definition and Purpose 153
Legal Requirements 154
Responsibilities 156
Board Structure and Activities 159
Summary 161
Five: Healthcare Professionals 163
Physicians 164
History of Western Medical Care 164
History of American Medical Care 177
Current Status of Medical Training 190
Licensure 197
Shortage of Physicians 199
Employment Status 204
Summary 206
Nurses 206
Registered Nurses 206
Nurse Practitioners 208
Nurse Anesthetists 209
Midwives 210
Education and Certification 212
Physician Assistants 213
Education and Certification 214
Physician versus NP/PA Care 215
Summary 216
Six: Payers 219
Principles of Health Insurance 220
The Loss Must Have Some Nontrivial Value Upon Which Both Insured and Insurer Agree 222
The Peril Must Occur Randomly and Be Out of the Control of the Insured 222
The Event Must Occur Neither Too Frequently Nor Too Rarely 225
The Insurer Must Be Able to Write Large Numbers of Contracts to Indemnify Similar Risks 226
Background and Current Status of Health Insurance in the United States 229
Private Health Insurance 229
Medicare 264
Medicaid 318
Children’s Health Insurance Program: Social Security Title XXI 335
Other Federally Sponsored Programs 337
Managed Care 357
Principles 361
Quality and Safety 361
Summary 381
Seven: Healthcare Technology 385
Definition and Frameworks for Study 386
Major Trends in Healthcare Technology 388
Safety 388
History of Safety Problems and Corrective Legislation 390
What Is Substantial Equivalence 404
When a 510(k) Is Required 404
Bringing Healthcare Technology to Market 435
Evolving Industry Structure 438
Globalization 444
Generics 444
Specialty Pharmaceuticals 446
Patents 453
Genomics and Precision Medicine 453
Disruptive Innovation 458
Healthcare Technology’s Contribution to Costs by Stage of Care 460
Overview 460
Quality-Adjusted Life Years 460
Core Cost Issues 462
Prevention 463
Screening 464
Diagnosis 464
Treatment 466
Other Considerations 470
Religious Issues 470
Ethical Issues 470
End-of-Life Costs 471
Media’s Role in Increasing Technology Costs 472
Malpractice and Defensive Medicine 473
Summary 474
Eight: Information Technology 475
Introduction 476
Definitions 477
Background and Key Issues in Health Information Technology 479
Collection, Classification, and Ordering of Data 479
Terminology/Coding 486
Interoperability 492
Lessons Learned 529
Challenges 529
Sustainability 529
Certification 534
Privacy and Security of Information 537
Management Considerations 547
Other Issues and Trends 549
Summary 563
Nine: Quality 565
Introduction 566
History of Healthcare Quality and Development of Key Concepts and Institutions 567
Ancient Origins 567
1900-1950 568
1950-1970s 574
1980s and Total Quality Management 580
1990s 589
2000-2010 592
2010-Present 605
Quality of Care and the Public’s Health 623
The Centers for Disease Control and Prevention 623
Healthy People 626
Definition of Quality 630
Key Questions for Successful Evaluation and Implementation of Quality Measures 632
Choosing Standards 633
Monitoring Standards 637
Evaluating Results 639
Volume/Quality Relationship 644
Managing Quality Improvement 646
Value Propositions 646
Cost-Quality Trade-off 648
Cost-Access Trade-off 648
Quality-Access Trade-off 649
Summary 649
Index 651
