1st Edition
Analyzing Form, Function, and Financing of the U.S. Health Care System
Analyzing Form, Function, and Financing of the U.S. Health Care System tells the story of the U.S. health care system by using a narrative approach identifying function rather than the more common data-driven focus on structure. It presents policy decisions we have made about our health care system and analyzes some of their consequences to better understand the choices we have. To facilitate this, the book is divided into four major sections.
Section I is mostly "about" the health care system. It describes several theoretical models that provide a foundation for the structure of the U.S. health care system. Section II provides a description of the form, or organization, of the U.S. health care delivery system. It presents a comprehensive overview of the entire health care delivery system, including identifying all levels of care.
Section III focuses on financing, beginning with a description of the economic and political values that determine how we finance our system. It describes health insurance, from the perspective of both the consumer and the provider, and discusses how money moves through the system. It concludes with a discussion and analysis of cost and cost control efforts.
Section IV describes some of the more important efforts in health care reform, including several targeted programs that are a significant part of the U.S. health care system, such as Medicare and Medicaid. It also describes other targeted programs within the U.S. health care system and explores how other countries with economies similar to that of the United States organize and finance their health care systems.
INTRODUCTION: SETTING THE CONTEXT
Definitions of Health and Illness
Health and Illness: Language Issues
Modification of the Biomedical Model: Epidemiological Model
Stress as Cause of Illness
Models of Health Not Illness
From Language to Behavior: Access
Health Belief Model Helps Explain Utilization
Health Care System or Medical Care System?
Acknowledgments
Public Health: Defining Determinants of Health
What Are Determinants of Health?
Why Do Health Determinants Matter?
Healthy People Initiative
Acknowledgments
Health Status Indicators
Measuring Death: Mortality Rates
Measuring Diseases: Morbidity Rates
Life Expectancy Rates
Other Measures of Health Indicators
What to Do with This Information?
Acknowledgments
Role of Culture in the Organization of Health Care Delivery Systems
Role of Culture in Defining Health and Illness
Impact of Culture on Organized Health Care Systems
Alternative or Complementary Medical Systems and Practices
Culturally Based CAM Medical Practices
Nonculturally Based CAM Healing Practices
What Really Works?
Acknowledgments
Political and Philosophical Values That Influence the U.S. Health Care System
The Private Market and the Role of Government
Cultural Belief in Science and Technology—Sometimes
When Political Values Restrict Health Care Services
Acknowledgments
FUNCTIONAL DESCRIPTION OF THE U.S. HEALTH AND MEDICAL CARE SYSTEM
Do We Have a System? A Functional Analysis
Describing the Health Care System: The Numbers
Functional Description: Levels of Care
Resource Implications of Levels of Care: Issues of Balance
Acknowledgments
People Who Make the Medical Care System Go: The Workforce
Physicians: The Story of Professionalization and the Development of the Biomedical Model
Mid-Level Independent Clinicians
The Nursing Profession
Other Independent Clinical Providers
Clinical Providers with Varying Levels of Practice Independence
Policy Issues
Acknowledgments
Hospitals
History
Classification of Hospitals
Organization and Management of Hospitals
Licensure, Accreditation, and Regulation
Hospital Finance and Controlling Costs
Summary and Policy Issues
Acknowledgments
Ambulatory Care: Functions, Structures, and Services
Settings for Ambulatory Care Services
What Is Primary Care?
Managed Care Concepts
Summary and Policy Issues
Acknowledgments
Other Components of the Medical Care System
Mental Health Care System
Long-Term Care System
Dental and Vision Care Systems
Summary
Acknowledgments
POLITICAL AND ECONOMIC VALUES AND HEALTH CARE FINANCING
Health Economics 101: Do Health Care Goods/Services Follow Standard Economic Rules?
Very Simple Health Economics Guidelines
Are Health Care Goods and Services Examples of Public Goods?
An Important Economic Concept: Elasticity
Market Justice versus Social Justice: Where to Go Next?
Acknowledgments
From Economics to Health Policy and Regulation
What Is Health Policy?
Who Creates and Implements Health Policy?
How Can We Tell If a Policy Works?
Examples of Policies and Links to Models of Allocation
Summary
Acknowledgments
Health Care Financing: Health Insurance
What Is Health Insurance and Why Do We Have It?
Consumer Responsibilities: What Do We Pay for and What Does Health Insurance Pay for?
History of the Health Insurance Industry in the United States
Types of Health Insurance
What about the Uninsured?
What Difference Does Health Insurance Make?
Summary
Acknowledgments
Health Insurance: Two Conceptual Models
Model I: Conventional Indemnity Health Insurance
Model II: How to Control Increasing Costs—HMO Insurance Model
From Conceptual Model to Early Implementation
From HMOs to Managed Care Plans
Summary
Acknowledgments
The Payment Function: Money Moving through the System
The Payment Function in Medicare
Payment Function: Medicaid
Payment Function: Private Insurance
Consequences of the Payment Function in the U.S. Health Care System
Another Way to Look at the Payment Function
Summary
Acknowledgments
Why Does Medical Care Cost So Much and What Can We Do about It?
What Is Cost in the Health Care System?
How Much Do We Spend and on What?
Demand: Role of "Us" in High Health Care Costs
Supply Factors: Influence Felt throughout the Health Care System
Costs as a Result of the Financing System
Costs Arising from the Medical Treatment Process
Cost Control: Approaches and Targets
What Is the Real Problem?
Acknowledgments
HEALTH CARE REFORM IN THE UNITED STATES: TARGETED PROGRAMS AND CONSEQUENCES
Health Care Reform: Past as Prologue to Present
The Foundation
Too Close for Comfort
Health Insurance Becomes an Employment Benefit
Health Care as Part of a Social Services Network
HMOs: The Beginning of Managed Care
Clinton and the Free Market
The ACA Builds on the Past
Where Are We at Today?
Acknowledgments
Taking Care of the Elderly: Medicare
The Target Group: Changes over Time
Medicare: A Four-Part Program
So, How Good Is Medicare?
Challenges Facing Medicare: Suggested Policy Changes
Summary
Acknowledgments
Taking Care of the Poor: Medicaid
Who Is Poor: Definitions of Eligibility
Financing and Administration of Medicaid: Federal and State
Who Is Covered under Medicaid?
What Does the Medicaid Program Cover?
State Modifications of Financing and Coverage
Does Medicaid Do What It Was Designed to Do?
Another Way to Think about This
Acknowledgments
Taking Care of Almost Everybody Else
Programs Focusing on Low-Income Children
Poor, Frail, Elderly: The Program of All-Inclusive Care for the Elderly
A Public Health Approach: CHCs
Too Sick to Be Insured: The State Approach
Workers’ Compensation Programs
Indian Health Services
Military and Veterans Health Services Systems
Does the Targeted Program Approach Work?
Acknowledgments
A Persistent Problem: Racial and Ethnic Disparities in Health Outcomes
What Are Health Disparities?
How Health Disparities Are Investigated
What Can Be Done about Health Disparities?
Where Are We Today?
Acknowledgments
Alternative Models for Health Care Systems: International Perspectives
What Countries Should We Examine?
Overall Description of Health Care System and Demographic Features
Financing and Cost Sharing
Resources
Indicators of Utilization and Financial Access
Selected Health Status Indicators
What Can We Learn from These Health Systems?
Summary and Final Thoughts
Acknowledgments
References
Biography
Dr. Paula Stamps Duston earned her PhD degree from the School of Public Health at the University of Oklahoma. She currently is teaching in the Commonwealth Honors College at the University of Massachusetts and serves as the graduate program director for public health in the university’s School of Public Health and Health Sciences. She is best known for her research in developing validated scales to measure the level of satisfaction of direct care providers, including both nurses and physicians. Her nurse satisfaction instrument, the Index of Work Satisfaction (IWS), is the most widely used in the field and is recommended by the American Nursing Association and JCAHCO for use as a quality indicator.
