Introduction to and History of Modern Healthcare in the US - Lecture A

Editor's Notes

• #2: Welcome to Introduction to Health Care and Public Health in the U.S.: Introduction to and History of Modern Health Care in the U.S. This is lecture a. 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 Introduction to and History of Modern Health Care in the U.S. are to: Define key terms in health care and public health, Describe components of health care delivery and health care systems, Discuss examples of improvements in public health,
• #4: Define core values and paradigm shifts in U.S. health care, And describe the technology used in the delivery and administration of health care.
• #5: This introductory lecture will provide a high level perspective as well as some important definitions. We will begin by defining the term “health.” We often think of health as the absence of disease but this is a somewhat narrow description of the term. In 1946, representatives of 61 countries attended the International Health Conference in New York to ratify the Preamble to the Constitution of the World Health Organization, which is the specialized agency of the United Nations that deals with global health. The WHO definition of health is that health is the state of complete physical, mental, and social well being and not merely the absence of disease or infirmity. Thus, illness represents a state of poor health.
• #6: Let’s look at the term “health care.” Health care is the prevention and treatment of illness. It is delivered by people who are drawn from different and often disparate disciplines, including medicine, dentistry, nursing, laboratory science, pharmacy, and other allied health professions which may include anesthesia technologists, cardiovascular technologists, medical assistants, perfusionists or respiratory therapists. As you can see, these people have different backgrounds, and they have disparate training, but often work together as interdisciplinary teams in order to deliver care to patients.
• #7: Health care is delivered in different places. In this unit, we are going to define and look at in-patient facilities, including nursing and residential care, and out-patient facilities.  When we think of in-patient facilities, we typically think of hospitals. Hospitals are institutions that treat patients who are sick or injured. Hospitals are physical structures that house patients during treatment and allow clinicians to conduct diagnostic tests and perform management interventions and specialized functions such as surgery or managing childbirth.  Historically, hospitals were places for shelter, or alms-houses for the poor. In 1946, the Hospital Survey and Construction Act was passed – this act was known as the Hill-Burton Act, since it was sponsored by Senator Lister Hill of Alabama and Senator Harold Burton of Ohio. This law provided federal grants to improve the physical infrastructure of hospitals and led to significant augmentation of the infrastructure of facilities that provided in-patient care in the United States.
• #8: There are different types of hospitals. Hospitals can provide general, medical, and surgical care. But some hospitals may provide specialty services that focus on a particular aspect of care, such as orthopedics, pediatrics, or women’s services. Some hospitals focus on mental health, or psychiatric care. Hospitals may be publicly or privately owned. Public hospitals may be administered by the city, county, state, or at a federal level. Privately owned hospitals may be not-for-profit, or may pursue profits like any other business. Patients may be admitted to a hospital one of two ways. They may go into an emergency room where they are evaluated by a team of clinicians. If the clinicians feel that the person is sick enough, they may admit the person into the hospital for care. Patients may also be directly admitted to hospitals from physician’s offices.
• #9: Let us now turn our attention to health care delivery in nursing and residential care facilities. These can be short-term facilities where it is anticipated that patients will stay for a brief period of time before returning home or to their residences, or long-term facilities where patients may stay for an extended or indefinite period of time. An example of a short-term facility would be a post-surgical rehabilitation center. After surgery, it may be deemed that a patient is too frail to return home and may need to spend some time in a rehabilitation center before gaining enough strength to return home. An example of a long-term facility might be an Alzheimer’s unit in a nursing home. A patient with gradually progressive dementia may need to stay indefinitely in such a facility. Long-term care is classified by the level of care. For example, a patient with relatively few health needs may reside in an assisted living facility, whereas a patient with profound and significant health needs may need the services of a nursing home. Skilled nursing facilities, also called nursing homes, initially proliferated after an amendment of the Social Security Act. They were originally part of the welfare system and gradually shifted to become a part of the current health care system.
• #10: In 1969, as the cost of Medicare increased, the then Department of Health and Human Services drastically reduced coverage for nursing homes. A year later, the Miller Amendment established a new standard called intermediate care. Intermediate care facilities didn’t require the same amount of skilled nursing or resources thus requiring reduced levels of reimbursement. In the 1990s another standard, sub-acute care, was defined to provide care for patients discharged from hospitals who briefly needed a higher level of care than was provided to a majority of patients in a skilled nursing facility. These distinct levels of care have been delineated primarily from the cost-effectiveness perspective.
• #11: Let’s now spend some time talking about health care delivery in the outpatient setting. Outpatient facilities may be physicians’ offices, dental offices, medical and diagnostic laboratories, or other ambulatory health services. Physician’s offices may be focused on primary, family, or specialty care. Family practice typically includes family care, internal medicine, and pediatrics, but also may focus on a particular specialty. These specialty care offices may represent medical specialties, such as gastroenterology or cardiology; surgical specialties such orthopedics or neurosurgery; or may reflect mental health care in the outpatient setting.  These offices are physical structures and though they may be present in close proximity to inpatient facilities, many physicians’ offices exist in the communities they serve and some of them may be quite far from hospitals. These offices may be single-specialty, where all the physicians practicing in a single office are of the same field such as family practice or internal medicine, or they may be multi-specialty offices, where an internal medicine practitioner may share space with an orthopedic surgeon. Dental offices may be those of general dentists, or specialists such as orthodontists, endodontists, or oral surgeons.
• #12: When we think of laboratories, we think of medical and diagnostic laboratories. Diagnostic laboratories are typically involved with imaging: x-rays, C-T scans – also called Computerized Axial Tomography scans or CAT scans - Magnetic Resonance Imaging, or MRIs and mammograms. Ultrasound imaging centers are examples of diagnostic laboratories. Medical laboratories usually deal with biologic specimens such as blood, cytology, or bacteriologic specimens. Specialized medical laboratories include DNA testing laboratories, medical pathology laboratories, parasitology and mycology health laboratories, toxicology health testing, and facilities that deal with non-radiologic, non- x-ray testing services. Examples of other ambulatory health services include ambulance services, home health care, blood and organ banks, hearing and vision screening facilities, smoking cessation programs, hospice services, and visiting nurse services.
• #13: The health care industry is one of the largest industries in the U.S. In 2014, 18 million jobs for wage and salary workers came from this industry. This is estimated to grow to 21.9 million jobs by 2024. The top four fastest growing job categories include home health care services, outpatient care centers, offices of other health practitioners, and other ambulatory health care services.
• #14: Let’s take a look at health care systems. A book by Askin and Moore, The Health Care Handbook, started as an e-book by two medical students who wanted to better understand the U.S. health care system. Both are now physicians and they have continued to update the book. It gives an overview of the U.S. health care system. They describe all the different types of practitioners and organizations that are part of the U.S. health care system. Another interesting book is one by TR Reid, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. Reid is a journalist from the Washington Post who had some common chronic medical problems. He went across the world to experience different health care systems and his book provides a comparative overview of the various models of health care around the world.
• #15: In his analysis of comparative health care systems, Mr. Reid comes up with four basic systems or models. He has names for these, describes them, points out the countries that use them, and shows that each of these models is used in different segments of the U.S. health care system. The first of these is the Beveridge model, which was developed in Great Britain and has health care that is provided and financed by the government. We all know the British National Health Service. This approach is also used in Hong Kong, an example of a capitalist country, and in Cuba, an example of a socialist country. In the U.S., this model is used in the Veteran’s Administration, or VA system, where care is provided and financed by the government. The second model is the Bismarck system. This is a system where there is highly regulated private insurance. There are usually rules that everyone must be covered and that pre-existing conditions must be covered as well. Often times, the coverage is tied into employment, and the major example of the Bismarck model is Germany, where Bismarck was from, although France, Switzerland, and many other European countries use this model. While we don't have this model exactly in the U.S., the employer-provided health insurance that most who are employed have is the closest example of the Bismarck model in the U.S. The third model is the national health insurance model. This is a private health care system with government-financed insurance. Canada is probably the best known model of this approach, although other countries like Taiwan and South Korea use it. The closest analog in the U.S. is Medicare, and Medicaid to some extent. The final model is out-of-pocket health care, where individuals pay as they go. Most poor countries around the world that cannot afford a comprehensive health care system use this approach, which basically ends up having those who have wealth being able to get health care and those who don't have wealth not being able to get it. There are many citizens in the U.S. who function under this model, namely those who lack health insurance. One point that Reid wanted to make was that there are different models and the U.S. has within its system people who are covered by the approach of each of these four models.
• #16: It is also important when talking about health systems to understand the different types of care: primary, secondary, and tertiary. Primary care is that initial and ongoing care that is typically provided in a physician’s office or in a clinic, and is sometimes provided by non-physician practitioners. But primary care is also the ongoing longitudinal care that may take place in a clinic or in an academic medical center. However, the type of care is characterized by an ongoing relationship between the patient and either a single or multiple health care providers. Secondary care is the specialty care that is provided in the community, such as when a patient is referred for a test to a local specialist or hospitalized in their local community for a test or surgical procedure. Finally there is tertiary care. This is highly specialized care that is usually provided by referral to some sort of large medical center. Often these large medical centers are academic medical centers but they don't necessarily need to be. The key of tertiary care is that the patient is away from the primary and secondary care that they've received initially. Sometimes primary and secondary care can be provided in academic medical centers and in hospitals, but tertiary care is that highly specialized care offered by many subspecialists who are not readily available in the patient's community.
• #17: Another important aspect of health care systems is to understand the different stakeholders, all of whose names start with the letter “p.” First and foremost, obviously, is the patient, the one who gets health care. Sometimes this individual may be referred to as a consumer or citizen, especially when they are well, and not a patient seeking care in the health care system. There are also providers, although some take issue with that term, but that is an umbrella term for all of those people and organizations who provide health care professionally. This includes physicians, nurses, allied health professionals, and others. Purchasers are those who buy health care in the United States. For most people who are employed, the purchaser provides a health insurance benefit to the individual. Another big purchaser of health care in the United States is the government, through Medicare, Medicaid, and other government programs. The payor actually pays the dollars for the health care. This is typically insurance companies, at least in the United States. Thus, the employer may purchase the health insurance, but then, the health insurer is the payor that pays for the care. Sometimes the government is the payor as well as the purchaser. Finally, there is the public health system that aims to protect the public's health through activities such as clean water, food sanitation, clean air, preventive measures, and so forth.
• #18: Another important aspect of understanding health care system is the financing of health care. People do not always understand the difference between paying for health care and paying for health insurance. The reality is that unless people are extraordinarily wealthy, they typically pay for insurance and not care. No matter which of the types of health care systems people live in, their care is financed by insurance. The notion of insurance is that everyone pays some and those who need it use it. However, we increasingly mandate that various things are paid for with insurance, so instead of being a pure insurance system we have moved to somewhat of a prepaid health care system, where essentially, we pre-pay for our health care.
• #19: Different payment methods have evolved over the years. The predominant method in the United States in the last century was private fee-for-service insurance. In this approach, individuals who had insurance would go to the physician or the hospital. Whatever care was provided to them was paid for by the insurance company. Pure fee-for-service started to become unsustainable due to a move towards managed care, manifested in the 1990s by health maintenance organizations, or HMOs, or other types of models such as preferred provider organizations, or PPOs, where patients needed to get their care within a network. In PPOs, the physicians and hospitals that were part of the network would have some financial constraints put on them. Another payment method is government-paid insurance. The most common approach is single-payor, where basically the individual gets health care and the government reimburses the physician or hospital. Finally, there is government-provided care, were there are government owned and run physician offices, hospitals, and other parts of the health care system.
• #20: As with all insurance, some people use more health care services than others. This is true of any type of insurance, whether auto insurance, homeowners insurance, or others. With health care, there are a small number of individuals who actually account for a large amount of the spending. If we look at some data from the United States, we see that the top 5% of spenders account for about 50%, or half, of all spending. The top 1% of spenders account for 23%, or about a quarter of all spending.
• #21: Health care finance has evolved over the last half-century. Starting in the middle of the 20th century was when many medical technologies first came to the fore, and it became clear that people could not just pay for the services that they used. So in the middle of the 20th century, health insurance was introduced, with the notion that everyone paid into a pool, and those who needed it, used it. This was the beginning of what some call “open-ended spending” with the fee-for-service model, in which insurance would just pay the bills, with little restriction based on quality-ensuring criteria such as the cost-effectiveness or the evidence basis of treatments being offered. Towards the latter part of the 20th century, this system started to become increasingly expensive, with no ability to control costs. This led to efforts that aimed to control costs, and to what we now call managed care, where constraints are put on spending. At the same time, the late 20th century saw the empowerment of patients and consumers to play a more active role in health care, aided in part by the growth of the Internet, which made information more widely available.
• #22: Now, in the 21st century, costs have continued to rise, although they have leveled off some in recent years. But we are still on this collision course with increasing costs, aging baby boomers, more costly technology, and other aspects that will continue to make financing health care a challenge.
• #23: Finally, with regards to health care systems, let's talk about health care payors in the U.S. Recall that payors are the entities that take money and pay health care provider organizations for care. The major type of payor in the U.S. continues to be private health insurance, particularly for most of those who are employed and their dependents, except those who are in lower paying jobs where health insurance is not provided as an employment benefit. Medicare is government-financed insurance, where the federal government is the payor for insurance. Medicare is provided to elderly and disabled individuals. Medicaid has historically been the government insurance program for the indigent, in other words, those who are poor. However, Medicaid is expanding substantially under the Affordable Care Act.
• #24: There is also a government insurance program for low-income children called the State Children’s Health Insurance Program, or S-CHIP. Finally, there are many other health care expenses that people have, either those who have no insurance or out-of-pocket expenses for those who do. There are also public health expenditures that are typically made by governments, whether federal, state, or local, and other kinds of expenditures on health-related items.
• #25: This table reflects the organization of the health care industry, and shows the percent distribution of employment in establishments in the health services sector in 2008. You can see that about eighty-seven percent of establishments and forty-two percent of employment are in ambulatory health care services. And you can see in this table that hospitals comprise one-point-three percent of establishments, but employ thirty-four-point-six percent of the people who work in the health care industry. Nursing and residential care facilities are about eleven percent of the establishment and employ about twenty-three percent of workers in the health services sector.
• #26: This concludes lecture a of Introduction to and History of Modern Health Care in the U.S. In summary, this lecture has defined three important terms - health, health care, and health care systems. There are many different types of health care delivery, ranging from in-patient facilities, which include hospitals, and short- and long-term care facilities, to out-patient facilities, where patients visit for specialty care and laboratory work. Finally, health care systems vary greatly from country to country. Most systems are characterized by a combination of public and private funding.
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