Delivering Healthcare (Part 1) Lecture C

Editor's Notes

• #2: Welcome to Introduction to Health Care and Public Health in the U.S.: Delivering Health Care, Part 1. This is lecture c. The component, Introduction to Health Care and Public Health in the U.S., is a survey of how health care and public health are organized and how services are delivered in the U.S. It covers public policy, relevant organizations and their interrelationships, professional roles, legal and regulatory issues, and payment systems. It also addresses health reform initiatives in the U.S.
• #3: The learning objectives for Delivering Health Care, Part 1 are to: Describe the organization of health care at the federal, state, and local levels. Describe the organization of the VA system and Military Health System. Describe the structure and function of hospital clinical and administrative units. And, describe different types of long-term care facilities, with an emphasis on their function.
• #4: This lecture discusses outpatient and inpatient care facilities. Relevant health care facilities include individual and group physician practices, health maintenance organizations, or HMOs, preferred provider organizations, or PPOs, urgent or immediate-care clinics, and hospitals. The different types of hospitals and their clinical and corporate structures, including hospital systems, will be discussed.
• #5: A sole proprietorship outpatient clinic is generally a small private office in which a physician works alone, assisted by one person or, at most, a few medical assistants and administrative personnel. Because of legal and financial liabilities for the physician, this form of practice is increasingly rare.
• #6: Two or more physicians may practice medicine together in what is called a partnership. One or both of the “partners” can actually be a corporation, rather than a person. In a corporate group practice, a hospital or corporation owns the practice and the physicians are employees, each earning a salary. An Independent Practice Association, or IPA, is another type of group practice where physicians work together to provide services while sharing economic risk. The IPA is a registered legal entity such as a corporation, a partnership, or a foundation. Each physician runs his or her own office, maintaining separate medical records, support staff, and professional identities. The physicians themselves own the IPA. Although distinct from HMOs, IPAs may contract with HMOs to provide services to HMO patients.
• #7: Managed care began in the late 1970s in an attempt to improve health care while controlling costs. An HMO is a prepaid health plan that provides health care for members and their families. The HMO contracts with physicians and hospitals, which are called the provider network. The HMO pays the physician a certain amount for each patient, and the patient pays a small fee, or co-payment, at each visit. Patients must use providers in the network and obtain a referral before accessing specialty care. A PPO is similar to an HMO, except that the physicians operate independently. The PPO network may be organized by an insurance company, an employer, or by the physicians themselves. Plan members pay a deductible and a co-payment. Members do not need a referral to see a specialist, but fees may be lower if they do obtain a referral. Point-of-service plans are essentially a combination of HMOs and PPOs. Patients can use physicians in the provider network, as in an HMO, but they can also go out of network without a referral, as in a PPO. The catch is that out-of-pocket costs are higher for using the PPO option.
• #8: There are different types of health care facilities where patients receive medical care. Urgent care centers, also called immediate care centers, are community clinics that provide care on a walk-in basis. These centers are intended for acute illnesses or injuries that need immediate care but are not serious enough for a hospital emergency department, or ED. The word “acute” refers to an illness that has started or worsened in a fairly short amount of time. Urgent care centers do not have all the medical capabilities or around-the-clock operation characteristic of an ED. However, they are better equipped and have longer office hours than general clinics. Urgent care centers are considered advantageous to the health care system, because they allow more people to access care, and they reserve EDs for more life-threatening conditions.
• #9: One of the reasons people use ERs is that they cannot pay for health care. To alleviate this problem, community health centers provide primary care for all individuals, regardless of insurance status or ability to pay. Located in all 50 states and U.S. territories, community health centers treat those living in poverty, people experiencing homelessness, public housing residents, migrant workers, and others. Most community health centers rely on public financing. Like urgent care clinics, community health centers enhance access to health care and treat people who would otherwise go to hospital EDs. Community mental health centers provide mental health outpatient services to similar populations.
• #10: Community hospitals are technically defined as non-government, short-term general hospitals that are open to the public. Despite the designation of “general,” some community hospitals specialize in certain fields, such as obstetrics and gynecology, rehabilitation, or orthopedics, and some are academic or teaching institutions. Community hospitals may operate on a for-profit or nonprofit basis. Community hospitals play an important role in the delivery of health care. They are perfectly suited for routine illnesses or surgery, providing a cost-effective and accessible option for local residents.
• #11: Teaching and research hospitals are usually large institutions affiliated with medical schools. Physicians there are aware of all the latest medications, surgical procedures, equipment, and technology. Because of this, teaching hospitals are capable of treating complex medical problems, such as rare diseases, and they perform special types of surgery. Teaching hospitals provide instruction for physicians and other health care providers, support and perform medical research, offer special services such as burn centers, and perform a charitable function by treating uninsured patients. A well-known example of a teaching hospital is Massachusetts General Hospital in Boston, which is affiliated with Harvard Medical School.
• #12: A critical access hospital is one that is certified to receive Medicare reimbursement for services. Medicare is the government insurance program for older people and some people with long-term disabilities. Typically, critical access hospitals are acute care hospitals in rural areas, although smaller health clinics may be eligible. In many cases, Medicare reimbursement saves these hospitals from having to close because of financial difficulty. They can therefore continue to provide services in areas that may otherwise lack hospital care.
• #13: It is important to note that hospitals and other health care facilities are accountable for their performance. In the U.S., an organization called the Joint Commission evaluates and certifies medical care facilities. The goal of the Joint Commission is to improve the effectiveness, safety, and overall value of health care. The Joint Commission is the oldest and largest accrediting body for health care in the U.S., and its judgments are considered fair because it is an independent nonprofit organization. The Joint Commission certifies nearly 21,000 organizations and programs in the U.S., including hospitals, urgent care centers, ambulatory clinics, surgery centers, and laboratories. These organizations undergo periodic on-site visits to identify and resolve problems.
• #14: Hospitals are structured according to type and level of care. Areas of the hospital with similar inpatients are called wards, such as the maternity ward or the pediatric ward for children. An “inpatient” is simply a person who has been admitted to the hospital. Other specialized areas include the emergency department, or ED, the operating room, or, and the intensive care unit, or ICU. There are different types of ICUs for specific patients; for example, a CCU is a cardiac care unit. Health care is provided mainly by physicians and nurses. Physicians may specialize in various types of medicine. All departments are assisted by ancillary personnel, who perform specific technical tasks.
• #15: Practically everyone has heard of the hospital ED, if only because of TV dramas. Open twenty-four hours a day, every day, the ED treats patients with a range of medical problems, whether relatively minor, such as an ankle sprain, or life-threatening, such as a heart attack, a drug overdose, or serious injuries. Physicians and nurses in the ED evaluate patients by a process called triage, whereby the sickest patients are treated first. After patients are treated, they may be able to go home right away. Those with more serious conditions are transferred to other areas of the hospital, possibly the ICU or CCU, for further care.
• #16: The OR, of course, is where surgery takes place. The environment is kept sterile, or free of germs, to prevent infection in the patient. The surgical team generally includes one or more surgeons, various nurses with specialized roles, and an anesthesiologist, who makes sure the patient is safely unconscious. Surgical instruments vary, depending on the operation to be performed. Equipment is available to monitor the patient’s vital signs and to resuscitate the patient in case of emergency. Surgery is also performed at freestanding surgery centers, which are separate from hospitals. Operations are done on an outpatient basis, meaning that the patient goes home directly afterward. As mentioned earlier in this lecture, surgery centers are also subject to Joint Commission certification.
• #17: The ICU is a separate area of the hospital for treatment and continuous monitoring of very ill patients. Many kinds of illnesses may need ICU care, including lung conditions such as pneumonia and emphysema; sepsis, or blood infection; and traumatic injuries. As mentioned earlier, CCUs are ICUs dedicated to patients with cardiac, or heart, disease. Patients may come to the ICU from another section of the hospital, such as the ED or the OR, or they may arrive after transfer from a different hospital. Machines in the ICU monitor the patient’s vital signs, such as breathing and heart rate. Various tubes may be inserted to give medicine, provide nutrition, or drain urine, and mechanical ventilators may be used to help with breathing. The need for other sophisticated equipment depends on the patient’s condition.
• #18: In most cases, people who provide acute care are emergency medicine physicians and critical care physicians, along with nurses and other personnel working as a team. Serious acute care encompasses medical problems such as heart attack, stroke, unexpected childbirth, or sudden complications of surgery. It also includes accidents such as poisoning, or trauma from such events as car crashes, gunshot or stab wounds, falls, or burns. Emergency medicine is a medical specialty dedicated to saving patients with life-threatening problems. It is a high-stress field where physicians must make difficult decisions quickly, often with limited information about the patient. The goal is short-term care, to immediately stabilize the patient so he or she can move on to more definitive treatment. Emergency physicians work in EDs. When possible, however, patients receive treatment from emergency medical technicians, or EMTs, before reaching the hospital. EMTs travel to sites of emergencies, perform basic medical care, and transport patients to hospitals by ambulance. Paramedics are EMTs with extra training that allows them to perform some medical procedures right at the scene, before transport.
• #19: Like emergency medicine, critical care is a specialty for treating patients with life-threatening conditions. In critical care medicine, however, the focus is on long-term care. The sickest patients are sent to the ICU or CCU after they are stabilized.
• #20: Hospitals employ many types of personnel. In the OR, of course, there are both surgeons and anesthesiologists. Surgeons perform operations, and many specialize in certain fields, such as orthopedic surgery, cardiovascular surgery, or plastic surgery. Anesthesiologists care for patients during surgery by monitoring their body functions while they are unconscious. They also treat pain outside the OR, such as in the ICU, during childbirth, and in medical conditions associated with chronic pain.
• #21: Medical specialties of physicians include general internal medicine, cardiology, obstetrics and gynecology, and psychiatry, among many others. There are even medical subspecialties, such as pediatric cardiology. Registered nurses, or RNs, licensed practical nurses, or LPNs, and physician’s assistants, or PAs, are thoroughly trained in their own right, and some of them specialize in certain fields of medicine. Pharmacists are licensed professionals who usually have a doctor of pharmacy degree. They are essential members of the hospital team who coordinate care activities, monitor patients for changes in physical condition, dispense medications, and provide support to patients and family members.
• #22: All hospitals employ personnel to provide ancillary services for diagnosis, treatment, rehabilitation, and education. Nursing assistants provide for the patient’s most basic needs, under the supervision of RNs or LPNs. The various types of technicians include phlebotomists, who are trained to take blood; x-ray and ultrasound technicians; and laboratory personnel. Rehabilitation personnel include physical therapists, occupational therapists, respiratory therapists, and speech therapists. Other hospital workers educate or counsel patients; these include dietitians, nutritionists, diabetes educators, and social workers. This is only a sampling of the roles that exist in hospital settings today.
• #23: The corporate structure of hospitals includes a governing board, or board of directors, that provides oversight. For nonprofit hospitals, the board of directors may be a religious order or influential figures in the health care community. Hospitals affiliated with universities may have the same board of directors as the university. In any corporation, the chief executive officer is responsible for daily operations. Most hospitals also designate chief medical officers, nursing officers, information officers, financial officers, and operating officers. Each department in a hospital has a head administrator who is responsible for its performance. In addition, departments are likely to have managers who oversee patient care, such as supervising physicians and nurse managers. Nonmedical service personnel, such as cooks and laundry workers, are also critical, as is the hospital business office that deals with such issues as billing and insurance, scheduling, maintenance of medical records, personnel issues, and reports and budgets.
• #24: Hospitals may be publicly or privately owned and funded, and they may be either for-profit or nonprofit. A public hospital is funded by the government and therefore may have limited financial resources. A private hospital is owned by a private organization, such as a medical insurance company. It tends to have greater capital and more up-to-date equipment, so its services may be more expensive.
• #25: A hospital system consists of two or more hospitals or other health care facilities that are owned, leased, or managed by an organization such as a corporation. Oversight is provided by a single board of directors. Single hospitals can be part of a hospital system if they own or lease other health care facilities. Health care networks are groups of hospitals, physicians, other health care providers, insurers, and/or agencies that collaborate to provide many types of health care in a community. One example of a hospital system is the Greenville Hospital System University Medical Center, a nonprofit organization located in South Carolina. The system includes five major medical centers and other facilities.
• #26: This concludes lecture c of Delivering Health Care, Part 1. In summary, health care facilities range from small offices of single physicians to large hospital systems. Most people obtain health care through managed care plans of various types. Community centers and freestanding clinics offer a range of services, from acute medical care or mental health care to outpatient surgery.
• #27: Hospitals of various types treat patients in the community, perform research and teaching, and provide care for the poor. All health care facilities are accountable for their effectiveness and safety performance. Health care practitioners work singly or together to provide the best possible emergency care, surgical services, critical care, long-term treatment, and ancillary services.
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