The U.S. healthcare system : origins, organization and opportunities

Author(s)

    • Shalowitz, Joel I.

Bibliographic Information

The U.S. healthcare system : origins, organization and opportunities

Joel I. Shalowitz

Jossey-Bass, c2019

  • : pbk

Available at  / 5 libraries

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Note

Includes index

Description and Table of Contents

Description

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. To keep the content current, online updates are provided at: healthcareinsights.md. 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

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