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Healthcare Delivery Systems

Integrated delivery system (IDS):

A system that combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care; See integrated provider organization (IPO)

Integrated provider organization (IPO):

An organization that manages the delivery of healthcare services provided by hospitals, physicians (employees of the IPO), and other health care organizations (for example, nursing facilities); See integrated delivery system

What do integrated delivery systems offer?

•Full range of healthcare services along a continuum of care to ensure that patients get the right care at the right time from the right provider
•The continuum extends from primary care providers to specialist and ancillary providers

What is the goal of IDSs?

To deliver high-quality, cost-effective care in the most appropriate settings

Continuum of care

The range of healthcare services provided to patients, from routine ambulatory care to intensive acute care

How are most hospitals integrated into their communities?

•Through ties with physicians and other healthcare providers
•Ties with clinics and outpatient facilities and other practitioners
•Almost half the nation's hospitals also are tied to larger orginizational entities such as multihospital and integrated healthcare systems (IHCSs), IDNs, and alliances

What is an IDN?

An IDN comprises a group of hospitals, physicians, other providers, insurers, and/or community agencies that work together to deliver health services.

Integrated Delivery Network (IDN)

See integrated delivery system
A system that combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care; See integrated provider organization

In 2008, what was the total percentage of community hospitals were in IDNs? What do multihospital systems include?

•In 2008, 1,490 community hospitals (29 percent of the total) were in IDNs (AHA 2009).
•Multihospital systems include two or more hospitals owned, leased, sponsored, or contract managed by a central organization.

What percentage of hospitals were in systems in 1985, and what was the change from that time to 2008?

•In 1985, 27.5 percent of hospitals were system members, which rose to 57 percent by 2008 (AHA 2009)

What is an alliance? How many hospitals were in group-purchasing orgs by 2000?

An alliance is defined as a formal organization, usually owned by shareholders/members, that works on behalf of its individual members in the provision of services and products and in the promotion of activities and ventures (AHA 1999)
•In 2000, 3,344 hospitals were in group-purchasing organizations (the dominant kind of alliance)
•The same hospitals can be registered in more than one category (AHA 2004)

What pressures were put on hospitals in the 1990's?

U.S. hospitals really begin to feel pressure to contain costs, improve quality and demonstrate their contributions to the health of the communities they serve

How did hospitals adapt to these pressures in the 1990's?

•Merged with or bought out other hospitals and healthcare organizations
•Created IDSs to provide a full range of healthcare services along the continuum of care, from ambulatory care to inpatient care to long-term care
•Concentrated on improving the care they provided by focusing on patients as customers
•Many hospitals responded to local competition by quickly entering into affiliations and other risk-sharing agreements with acute and nonacute care providers, physicians' groups, and managed care organizations (MCOs)

Managed care organization (MCO):

A type of healthcare organization that delivers medical care and manages all aspects of the care or the payment for care by limiting providers of care, discounting payment to providers of care, and/or limiting access to care

At the close of the first decade of 2000, what stressors did healthcare organizations face?

•Challenges of a stressed economy
•High unemployment rates
•More uninsured individuals

What was the result of the stressors found in healthcare organizations by the end of the year 2000? And how was it handled?

•Hospital reimbursement payments continued to shrink
•Hospitals reached out for opportunities to control costs, streamline operations, implement efficient information technologies, engage in quality initiatives, and pursue joint ventures and consolidation

How much did the U.S. spend on healthcare associated with rising costs at the end of 2000? What did the government initiate as a response?

Associated with escalating costs the United States spent about $2.2 trillion on healthcare, representing 16 percent of the total economy
•Government initiated steps for reforming healthcare by:
-Instituting temporary measures to
make healthcare coverage more
affordable
-Providing incentives for
computerizing health records, and
-Investing in wellness and disease
prevention

What did congress pass regarding healthcare in 2010?

In 2010, Congress passed health care insurance reform legislation with the goals of reducing healthcare costs, protecting and increasing consumers' choices, and guaranteeing access to quality, affordable healthcare for all Americans

In what history is modern Western medicine rooted?

•Antiquity
•Ancient Greeks developed surgical procedures, documented clinical cases, and created medical books

Before modern times, what was folk medicine based on?

•European, African, and Native American cultures all had traditions of folk medicine based on spiritual healing and herbal cures
•The first hospitals were created by religious orders in medieval Europe to provide care and respite to religious pilgrims traveling back and forth from the Holy Land

It was not until the late 1800s that medicine became?

•A scientific discipline
•More progress and change occurred in the 20th century than during the preceding 2,000 years
•The past few decades have seen dramatic developments in the way diseases are diagnosed and treated and in the way healthcare is delivered

Before the advent of modern Western medicine, epidemics and plagues were common:

•Smallpox, measles, yellow fever, influenza, scarlet fever, and diphtheria killed millions of people. •Bubonic plague spread periodically through Europe and killed millions more
•Disease was carried by rodents and insects as well as by the travelers who moved along intercontinental trade routes

The medical knowledge that had been gained by ancient Greek scholars such as Hippocrates was _____ during the middle ages

Lost during the Middle Ages

What did The European Renaissance, a historical period beginning in the 14th century revive?

•Interest in the classical arts, literature, and philosophy as well as the scientific study of nature
•This period also was characterized by economic growth and concern for the welfare of workers at all levels of society

What came with the concept of concern for welfare of workers at all levels of society?

With this concept came a growing awareness that a healthy population promoted economic growth.

How did North America's first hospitals arise? And what need was recognized regarding new immigrants?

•Early settlers in the British colonies of North America appointed commissions to care for the sick, to provide for orphans, and to bury the dead
•During the mid-1700s, the citizens of Philadelphia recognized the need for a place to provide relief to the sick and injured
•They also recognized the need to isolate newly arrived immigrants who had caught communicable diseases on the long voyage from Europe

What did Benjamin Franklin and other colonists persuade the legislature to develop for the community?

•Benjamin Franklin and other colonists persuaded the legislature to develop a hospital for the community
•The Pennsylvania Hospital was established in Philadelphia in 1752, the first hospital in the British colonies
•(Almost 200 years earlier, Cortez established the first hospital in Mexico and it still serves patients today.)

In its first 150 years, the Pennsylvania Hospital was? What were the two subsequent hospitals?

•Was a model for the organization of hospitals in other communities
•The New York Hospital opened in 1771 and started its first register of patients in 1791
•Boston's Massachusetts General Hospital opened in 1821

Human anatomy and physiology and the causes of disease were not well understood before the 20th century. At one time, what was believed to determine a person's temperament? What were treatments as a result?

•It was believed that four basic fluids, called humors, determined a person's temperament and health, and that imbalances in the proportion of humors in the body caused disease. •Therapeutic bleeding of patients was practiced until the early 20th century
•Early physicians also treated patients by administering a variety of substances with no scientific basis for their effectiveness

Early medical education

•Early medical education consisted of serving as an apprentice to an established practitioner
•Just about anyone could hang out a shingle and call himself a physician

What did the medical profession soon recognize about medical training? What happened as a result?

•The medical profession recognized that some of its members achieved better results than others, and •Leaders in the profession attempted to regulate the practice of medicine in the late 1700s

Regulation:

•The first attempts at regulation took the form of licensure
•The first licenses to practice medicine were issued in New York in 1760
•By the mid-1800s, however, efforts to license physicians were denounced as being undemocratic and penalties for practicing medicine without a license were removed in most states

At what point did the demand for medical practitioners exceed supply? What happened as a result?

•As the U. S. population grew and settlers moved westward
•To staff new hospitals and serve a growing population, private medical schools began to appear
•By 1869, there were 72 medical schools in the United States

What was a mistake made by the first medical schools?

•These schools did not follow an established course of study and some graduated students with as little as six months of training
•The result was an oversupply of poorly trained physicians

American Medical Association (AMA):

The national professional membership organization for physicians that distributes scientific information to its members and the public, informs members of legislation related to health and medicine, and represents the medical profession's interests in national legislative matters

When and why was the AMA established? Who was it dominated by, and what lead to its reform?

•The American Medical Association (AMA) was established in 1847 to represent the interests of physicians across the country
•The AMA was dominated by members who had strong ties to the medical schools and the status quo. •Its ability to lead a reform of the profession was limited until it broke its ties with the medical schools in 1874
•At that time, the association encouraged the creation of independent state licensing boards

American Association of Medical Colleges (AAMC):

The organization established in 1876 to standardize the curriculum for medical schools in the United States and to promote the licensure of physicians

Which organizations campaigned for medical licensing? By the 1890s, was was established?

The AMA and AAMC

By the 1890s, 35 states had established or reestablished what?

•By the 1890s, 35 states had established or reestablished a system of licensure for physicians
•At that time, 14 states decided to grant licenses only to graduates of reputable medical schools
•The state licensing boards discouraged the worst medical schools, but the criteria for licensing continued to vary from state to state and were not fully enforced

What had become apparent by the early 20th century? What organization was divided on this issue, and how were they divided?

•That improving the quality of American medicine required regulation through curriculum reform as well as licensure
•Members of AMA were divided
•Conservative members continued to believe that the association should stay out of the area of regulation whereas progressive members supporte continued development of state licensure systems and creation of a standardized model for medical education

The division of AMA attracted the attention of who? What was offered as a response, and who undertook it?

•Carnegie Foundation for the Advancement of Teaching
•The president of the foundation offered to sponsor and fund an independent review of the medical colleges then operating in the United States
•Abraham Flexner, an educator from Louisville, Kentucky, undertook the review in 1906

Abraham Flexner

•1906 - over the next 4 years, Flexner visited every medical college in the country and carefully documented his findings

1910 report by Abraham Flexner: what was found? what was most important, and what was recommended?

•Given to the Carnegie foundation the AMA, and the AAMC
•Described the poor quality of the training being provided in the colleges
•Noted that medical school applicants often lacked knowledge of the basic sciences
•How the absence of hospital-based training limited the clinical skills of medical school graduates
•Most important-reported that huge numbers of graduates were being produced every year and that most of them had unacceptable levels of medical skill
•Recommended closing most of the existing medical schools to address the problem of oversupply

Reform initiatives that grew out of Flexner's report and from recommendations made by the AMA's Committee on Medical Education:

•Required medical school applicants to hold a college degree
•Required that medical training be founded in the basic sciences •Required that medical students receive practical, hospital-based training in addition to classroom work

How were the reforms from Flexner's report carried out?

•These reforms were carried out in the decade following Flexner's report, but only about half the medical schools actually closed
•By 1920, most of the medical colleges in the United States had met rigorous academic standards and were approved by the AAMC

Today, medical school graduates must pass a test before they can obtain a license to practice medicine. Who administers? What else is required?

•The licensure tests are administered by state medical boards
•Many states now use a standardized licensure test developed in 1968 by the Federation of State Medical Boards of the United States
•However, passing scores for the test vary by state
•Most physicians also complete several years of residency training in addition to medical school

What must specialty physicians complete? What is required?

•Specialty physicians also complete extensive postgraduate medical education
•Board certification for the various specialties requires the completion of postgraduate training as well as a passing score on a standardized examination

The most common medical specialties include the following:

•Internal medicine
•Pediatrics
•Family practice
•Cardiology
•Psychiatry
•Neurology
•Oncology
•Radiology

The most common surgical specialties include:

•Anesthesiology
•Cardiovascular surgery
•Obstetrics/gynecology
•Orthopedics
•Urology
•Ophthalmology
•Otorhinolaryngology
•Plastic and reconstructive surgery
•Neurosurgery

Subspecialties

•Some medical and surgical specialists undergo further graduate training to qualify to practice
the subspecialties of internal medicine include endocrinology, pulmonary medicine, rheumatology, geriatrics, and hematology

Physicians also may limit their practices to the treatment of specific illnesses:

•For example, an endocrinologist may limit his or her practice to the treatment of diabetes

Surgeons

•Surgeons can work as general surgeons or as specialists or subspecialists
•For example, an orthopedic surgeon may limit his practice to surgery of the hand, surgery of the knee, surgery of the ankle, or surgery of the spine

Some physicians and healthcare organizations employ physician assistants (PAs) and/or surgeon assistants (SAs) to help them carry out their clinical responsibilities

•Such assistants may perform routine clinical assessments, provide patient education and counseling, and perform simple therapeutic procedures
•Most PAs work in primary care settings, and most SAs work in hospitals and ambulatory surgery clinics
•PAs and SAs always work under the supervision of licensed physicians and surgeons

Religious organizations:

In the 19th century and the first part of the 20th century, they sponsored more than half the hospitals in the United States
•Members of religious orders often provided nursing care in these organizations
•As the U.S. population grew and more towns and cities were established, new hospitals were built •Older cities also grew, and city hospitals became more and more crowded

Nursing in the late 1800s:

•In the late 1800s, nurses received no formal education and little training
•Nursing staff for the hospitals was often recruited from the surrounding community, and many poor women who had no other skills became nurses
•The nature of nursing care at that time was unsophisticated
•Lack of basic hygiene often promoted disease
•Many patients died from infections contracted while hospitalized for surgery, maternity care, and other illnesses

Beginnings of nurse training:

•In 1868, the AMA called the medical profession's attention to the need for trained nurses
•The public also began to call for better nursing care in hospitals
•The first general training school for nurses was opened at the New England Hospital for Women and Children in 1872
•It became a model for other institutions throughout the country. •As hospital after hospital struggled to find competent nursing staff, many institutions and their medical staffs developed their own nurse training programs

Nursing responsibilities in the late 19th and early 20th centuries:

•Housekeeping duties
•Cooked meals for patients in kitchens attached to each ward
•Direct patient care duties included giving baths, changing dressings, monitoring vital signs, administering medications, and assisting physicians
•During this time, nurses were not required to hold a license to practice

American Nurses Association (ANA):

•The national professional membership association of nurses •Works for the improvement of health standards and the availability of healthcare services, fosters high professional standards for the nursing profession, and advances the economic and general welfare of nurses

Founded in 1897 by a group of nurses attending the annual meeting of the American Society of Superintendents of Training Schools for Nursing

•Founded the Nurses Associated Alumnae of the United States and Canada
•In 1911, the organization was renamed the American Nurses Association (ANA)
•During the early meetings of the association, members established a nursing code of ethics and discussed the need for nursing licensure and for publications devoted to the practice of nursing

State nursing associations to advocate for the registration of nurses:

•At the turn of the 20th century, nurses also began to organize state nursing associations to advocate for the registration of nurses
•Their goal was to increase the level of competence among nurses nationwide

What was the opposition to nursing education, and what was passed despite this?

•Despite opposition from many physicians who believed that nurses did not need formal education or licensure, North Carolina passed legislation requiring the registration of nurses in 1903
•Today, all 50 states have laws that spell out the requirements for the registration and licensure of nursing professionals

Modern registered nursing requirements:

•Modern registered nurses must have either a two-year associate's degree or a four-year bachelor's degree from a state-approved nursing school. •Nurse practitioners, researchers, educators, and administrators generally have a four-year degree in nursing and additional postgraduate education in nursing
•The postgraduate degree may be a master's of science or a doctorate in nursing

Nonacademic training and nondegreed nursing personnel:

•Nurses who graduate from nonacademic training programs are called licensed practical nurses (LPNs) or licensed vocational nurses (LVNs). •Nondegreed nursing personnel work under the direct supervision of registered nurses. Nurses in all 50 states must pass an exam to obtain a license to practice

Nursing specialties and training:

Surgery, psychiatry, and intensive care
•Nurse-midwives complete advanced training and are certified by the American College of Nurse-Midwives. •Nurse-anesthetists are certified by the Council on Certification/Council on Recertification of Nurse Anesthetists
•Nurse practitioners receive advanced training at the master's level that qualifies them to provide primary care services to patients
•They are certified by several organizations (for example, the National Board of Pediatric Nurse Practitioners) to practice in the area of their specialty.

The need for registered nurses is expected to rise over the next decade.

•Hospitals in the United States report continued vacancies for registered nurses
•The Department of Health and Human Services estimates that over one million more nurses over the projected supply will be needed by 2020

1910, Dr. Franklin H. Martin

•Suggested that the surgical area of medical practice needed to become more concerned with patient outcomes
•Was introduced to this concept in discussions with Dr. Ernest Codman

Dr. Ernest Codman:

•Codman was a British physician who believed that hospital practitioners should track their patients for a significant amount of time after treatment to determine whether the end result had been positive or negative
•Codman also supported the use of outcome information to identify the practices that led to the best results for patients

Concern of Martin and other American physicians at this time (1910):

•They were concerned about the conditions in U. S. hospitals
•Many observers felt that part of the problem was related to the lack of organization in medical staffs and to lax professional standards. In the early 20th century, before the development of antibiotics and other pharmaceuticals, hospitals were used mainly by physicians who needed facilities in which to perform surgery •Most nonsurgical medical care was still provided in the home
•It was natural, then, for the force behind improved hospital care to come from surgeons

Push for hospital reforms:

•Led to formation of the American College of Surgeons in 1913

American College of Surgeons in 1913:

•The organization faced a difficult task. In 1917, the leaders of the college asked the Carnegie
•Foundation for funding to plan and develop a hospital standardization program
•The college then formed a committee to develop a set of minimum standards for hospital care
•It published the formal standards under the title of the Minimum Standards

During 1918 and part of 1919, American College of Surgeons:

•The college examined the hospitals in the United States and Canada just as Flexner had reviewed the medical colleges a decade earlier
•The performance of 692 hospitals was compared to the college's Minimum Standards
•Only 89 of the hospitals fully met the college's standards, and some of the best-known hospitals in the country failed to meet them.

The adoption of the Minimum Standards was the basis of:

•The Hospital Standardization Program and marked the beginning of the modern accreditation process for healthcare organizations
•Accreditation standards are developed to reflect reasonable quality standards
•The performance of each participating organization is evaluated against the standards
•The accreditation process is voluntary; healthcare organizations choose to participate in order to improve the care they provide to their patients

American Hospital Association (AHA):

The national trade organization that provides education, conducts research, and represents the hospital industry's interests in national legislative matters; membership includes individual healthcare organizations as well as individual healthcare professionals working in specialized areas of hospitals, such as risk management

Early 1950s accreditation:

•The American College of Surgeons continued to sponsor the hospital accreditation program until the early 1950s
•At that time, four professional associations from the U. S. and Canada joined forces with the college to create a new accreditation organization called the Joint Commission on Accreditation of Hospitals
•The associations were the American College of Physicians, the AMA, the American Hospital Association (AHA), and the Canadian Medical Association
•The new organization was formally incorporated in 1952 and began to perform accreditation surveys in 1953.

The Joint Commission (TJC) continues to survey several different types of healthcare organizations today, including:

•Acute care hospitals
•Long-term carefacilities
•Ambulatory care facilities
•Psychiatric facilities
•Home health agencies

Several other organizations also perform accreditation of healthcare organizations, including:

•The American Osteopathic Association (AOA)
•The Commission on Accreditation of Rehabilitation Facilities (CARF), and •The Accreditation Association for Ambulatory Healthcare (AAAHC)

After the First World War, many roles previously played by nurses and nonclinical personnel began to change.

With the advent of modern diagnostic and therapeutic technology in the mid-twentieth century, the complex skills needed by ancillary medical personnel fostered the growth of specialized training programs and professional accreditation and licensure.

According to the AMA, allied health incorporates:

The healthcare-related professions that function to assist, facilitate, and/or complement the work of physicians and other clinical specialists.

The Health Professions Education Amendment of 1991 describes:

•Allied health professionals as health professionals (other than registered nurses, physicians, and physician assistants) who have received either a certificate, an associate's degree, a bachelor's degree, a master's degree, a doctorate, or postdoctoral training in a healthcare-related science
•Such individuals share responsibility for the delivery of healthcare services with clinicians (physicians, nurses, and physician assistants)

Allied health occupations and growth:

•Allied health occupations are among the fastest growing in healthcare
•The number of allied health professionals is difficult to estimate and depends on the definition of allied health
•Unlike the case in medicine, women dominate most of the allied health professions, representing between 75 and 95 percent in most of the occupations
•All 50 states require licensure for some allied health professions (physical therapy, for example). P•ractitioners in other allied health professions (occupational therapy, for example) may be licensed in some states but not in others
•Significant shortages of personnel in many of the allied health disciplines are projected into the next decade

Some of the major occupations usually considered to be allied health professions: Audiology

•Audiology: Audiology is the branch of science that studies hearing, balance, and related disorders
•Audiologists treat those with hearing loss and proactively prevent related damage
•According to the American Speech-Language-Hearing Association, audiologists provide comprehensive diagnostic and treatment/rehabilitative services for auditory, vestibular, and related impairments
•These services are provided to individuals across the entire age span from birth through adulthood; to individuals from diverse language, ethnic, cultural, and socioeconomic backgrounds; and to individuals who have multiple disabilities

Some of the major occupations usually considered to be allied health professions: Clinical laboratory science:

•Originally referred to as medical laboratory technology, this field is now more appropriately referred to as clinical laboratory science
•Clinical laboratory technicians perform a wide array of tests on body fluids, tissues, and cells to assist in the detection, diagnosis, and treatment of diseases and illnesses

Some of the major occupations usually considered to be allied health professions: Diagnostic medical sonography/imaging technology:

•Originally referred to as x-ray technology and then radiologic technology, this field is now more appropriately referred to as diagnostic imaging
•The field continues to expand to include nuclear medicine, radiation therapy, and echocardiography
•These services are provided by physician specialists and technologists including radiation therapists, cardiosonographers (ultrasound technologists), and magnetic resonance technologists.

Some of the major occupations usually considered to be allied health professions: Dietetics and nutrition:

•Dietitians (also clinical nutritionists) are trained in nutrition
•They are responsible for providing nutritional care to individuals and for overseeing nutrition and food services in a variety of settings, ranging from hospitals to schools.

Some of the major occupations usually considered to be allied health professions: Emergency medical technology:

Emergency medical technicians (EMTs) and paramedics provide a wide range of services on an emergency basis for cases of traumatic injury and other emergency situations and in the transport of emergency patients to a medical facility.

Some of the major occupations usually considered to be allied health professions: Health information management:

•Health information management (HIM) professionals (formerly called medical record administration) oversee health record systems and manage health-related information to ensure that it meets relevant medical, administrative, and legal requirements
•Health records are the responsibility of registered health information administrators (RHIAs) and registered health information technicians (RHITs)

Some of the major occupations usually considered to be allied health professions: Occupational therapy:

Occupational therapists (OTs) evaluate and treat patients whose illnesses or injuries have resulted in significant psychological, physical, or work-related impairment.

Some of the major occupations usually considered to be allied health professions: Optometry:

•Optometry is a health profession focused on eyes and related structures, as well as vision, visual systems, and vision information processing in humans
•Optometrists provide treatments such as contact lenses and corrective and low vision devices, and are authorized to use diagnostic and therapeutic pharmaceutical agents to treat anterior segment disease, glaucoma, and ocular hypertension
•As primary eye care practitioners, optometrists often are the first ones to detect such potentially serious conditions as diabetes, hypertension, and arteriosclerosis.

Some of the major occupations usually considered to be allied health professions: Pharmacy:

•The scope of pharmacy practice includes traditional roles such as compounding and dispensing medications, as well as modern services including reviewing medications for safety and efficacy, and providing drug information to physicians and patients
•Pharmacists are the experts on drug therapy and are the primary health professionals who optimize medication use to provide patients with positive health outcomes.

Some of the major occupations usually considered to be allied health professions: Physical therapy:

•Physical therapists (PTs) evaluate and treat patients to improve functional mobility, reduce pain, maintain cardiopulmonary function, and limit disability
•PTs treat movement dysfunction resulting from accidents, trauma, stroke, fractures, multiple sclerosis, cerebral palsy, arthritis, and heart and respiratory illness
•Physical therapy assistants work under the direction of PTs and help carry out the treatment plans developed by PTs

Some of the major occupations usually considered to be allied health professions: Respiratory therapy:

•Respiratory therapists (RTs) evaluate, treat, and care for patients with breathing disorders
•They work under the direction of qualified physicians and provide services such as emergency care for stroke, heart failure, and shock, and treat patients with emphysema and asthma.

Some of the major occupations usually considered to be allied health professions: Speech-language pathology and audiology:

Speech-language pathologists and audiologists identify, assess, and provide treatment for individuals with speech, language, or hearing problems.

Some of the major occupations usually considered to be allied health professions: Surgical technologist:

•Provide surgical care to patients in a variety of settings; the majority are hospital operating rooms
•Surgical technologists work under medical supervision to facilitate the safe and effective conduct of invasive surgical procedures

Check your understanding 12.1:
1. What healthcare professional assists physicians in clinical assessments and patient education?

D. Physician assistants

Check your understanding 12.1:
2. Licensure tests to practice medicine are administered by:

D. State licensure boards

Check your understanding 12.1:
3. Which of the following statements is true about registered nurses?

B. Nurses are required to have a license in the state in which they practice

4. Which of the following professions is generally considered to be an allied health career?

A. Clinical laboratory science

5. To become board-certified in pediatrics, which of the following would an internal medicine physician need to do?

B. Complete graduate training in pediatric medicine and pass a national examination

6. The adoption of the Minimum Standards marked the beginning of what modern practice for healthcare organizations?

A. Accreditation

7. According to the AMA, which of the following incorporates the healthcare-related professions that function to assist, facilitate, and/or complement the work of physicians and other clinical specialists?

D. Allied health

Instructions: Indicate whether the statements below are true or false (T or F).

8. __F__ Respiratory therapists treat patients with limited mobility.
9. _F___ Physical therapy assistants develop treatment plans.
10.__T__ Cardiosonography is a specialization of diagnostic imaging technologists

Where was most healthcare provided until the Second World War? Quality in healthcare services at this time was considered a product of?

•In the home
•Appropriate medical practice and oversight by physicians and surgeons
•Even the Minimum Standards used to evaluate the performance of hospitals were based on factors directly related to the composition and skills of the hospital medical staff

20th century tremendous change

•Advances in medical science promised better outcomes and increased the demand for healthcare services
•Medical care has never been free
•Even in the best economic times, many Americans have been unable to take full advantage of what medicine has to offer because they cannot afford it

Concern over access to healthcare:

•Especially evident during the Great Depression of the 1930s
•Concern over access to healthcare was During the Depression, America's leaders were forced to consider how the poor and disadvantaged could receive the care they needed.

Medical care for poor and elderly: Healthcare at a cost in the 1930s

•Before the Depression, medical care for the poor and elderly had been handled as a function of social welfare agencies
•During the 1930s, however, few people were able to pay for medical care
•The problem of how to pay for the healthcare needs of millions of Americans became a public and governmental concern
•Working Americans turned to prepaid health plans to help them pay for healthcare, but the unemployed and the unemployable needed help from a different source

Prepaid healthcare or health insurance; blue cross

•Began with the financial problems of one hospital, Baylor University Hospital in Dallas, Texas
•In 1929, the administrator of the hospital arranged to provide hospital services to Dallas's schoolteachers for 50 cents per person per month
•Before that time, a few large employers had set up company clinics and hired company physicians to care for their workers, but the idea of a prepaid health plan that could be purchased by individuals had never been tried before.
•The idea caught on quickly, and new prepaid plans appeared across the country
•Eventually, these plans became known as Blue Cross plans when the blue cross symbol used by some of the new plans was adopted officially as the trademark for all the plans in 1939

Blue Shield plan

•Another type of prepaid plan, called the Blue Shield plan, was subsequently developed to cover the cost of physicians' services
•The idea for the Blue Shield plans grew out of the medical service bureaus created by large lumber and mining companies in the Northwest
•In 1939, the first formal Blue Shield plan was founded in California.
•Growth in the number of Blue Cross/Blue Shield (BC/BS) plans continued through the Depression and boomed during the Second World War •During the war-related labor shortages, employers began to pay for their employees' memberships in the Blues as a way to attract and keep scarce workers

Public funding for healthcare services:

•The idea of public funding for healthcare services also goes back to the Great Depression
•The decline in family income during the 1930s curtailed the use of medical services by the poor
•In 10 working-class communities studied between 1929 and 1933, the proportion of families with incomes under $150 per capita had increased from 10 to 43 percent

A 1938 Gallup poll asked people whether they had put off seeing a physician because of the cost.

The results showed that 68 percent of lower-income respondents had put off medical care, compared with 24 percent of respondents in upper-income brackets

The depression, incomes for physicians and hospitals and demand for free services:

•The decreased use of medical services and the inability of many patients to pay meant lower incomes for physicians
•Hospitals were in similar trouble
•Beds were empty, bills went unpaid, and contributions to hospital fundraising efforts tumbled
•As a result, private physicians and charities could no longer meet the demand for free services
•For the first time, physicians and hospitals asked state welfare departments to pay for the treatment of people on relief

The Depression posed a severe test for the AMA

•It was no easy matter to maintain a common front against government intervention when physicians themselves were facing economic difficulties
•Because of the economic hardships, many physicians were willing to accept government-sponsored health insurance

In 1935, the California Medical Association endorsed the concept of:

•Compulsory health insurance
•Because health insurance promised to stimulate the use of physicians' services and help patients pay their bills

What was the AMA's response to the economic crisis

•The AMA's response to the economic crisis emphasized restricting the supply of physicians, rather than increasing the demand for their services, by instituting mandatory health insurance
•The AMA reacted by pushing for the closure of medical schools and reductions in the number of new medical students.

How did the AMA adjust its position on health insurance?

•By the mid-1930s, however, the AMA began to adjust its position on health insurance
•Instead of opposing all insurance, voluntary or compulsory, it began to define the terms on which voluntary programs might be acceptable •Although accepting health insurance plans in principle, the AMA did nothing to support or encourage their development

The push for government-sponsored health insurance continued in the late 1930s during the administration of President Franklin D. Roosevelt

•However, compulsory health insurance stood on the margins of national politics throughout the New Deal era
•It was not made part of the new Social Security program, and it was never fully supported by President Roosevelt

Truman's health care plan:
What did compulsory health insurance become entangled with America's fears of?

•After WWII, the issue of healthcare access finally moved to the center of national politics
•In the late 1940s, President Harry S. Truman expressed unreserved support for a national health insurance program
•However, the issue of compulsory health insurance became entangled with America's fear of communism
•Opponents of Truman's healthcare program labeled it "socialized medicine," and the program failed to win legislative support.

When did the idea of national health insurance resurface?

The idea of national health insurance did not resurface until the administration of Lyndon Johnson and the Great Society legislation of the 1960s.

What was legislated in 1965 to pay the cost of providing healthcare services to the elderly and the poor? When was healthcare reform and national health insurance again given priority?

•The Medicare and Medicaid programs •The issues of healthcare reform and national health insurance were again given priority during the first four years of President Bill Clinton's administration in the 1990s
•However, the complexity of American healthcare issues at the end of the 20th century doomed reform efforts
•In 2010, Congress passed health insurance reform legislation that was signed into law by President Barack Obama

During the 20th century, Congress passed pieces of legislation w/a significant impact on the delivery of healthcare services in the United States:

•Biologics Control Act of 1902
•Social Security Act of 1935
•Hospital Survey and Construction Act of 1946
•Public Law 89-97 of 1965
•Public Law 92-603 of 1972
•Health Planning and Resources •Development Act of 1974
•Utilization Review Act of 1977
•Peer Review Improvement Act of 1982
•Tax Equity and Fiscal Responsibility Act of 1982
•Prospective Payment Act (1982)/Public Law 98-21 of 1983
•Consolidated Omnibus Budget •Reconciliation Act of 1985
•Omnibus Budget Reconciliation Act of 1986
•Healthcare Quality Improvement Act of 1986
•Omnibus Budget Reconciliation Act of 1990
•Mental Health Parity Act of 1996
•Health Insurance Portability and Accountability Act of 1996
•American Recovery and Reinvestment Act of 2009

Biologics Control Act of 1902

•Direct federal sponsorship of medical research began with early research on methods for controlling epidemics of infectious disease
•The Marine Hospital Service performed the first research
•In 1887, a young physician, Joseph Kinyoun, set up a bacteriological laboratory in the Marine Hospital at Staten Island, NY
•Four years later, the Hygienic Laboratory was moved to Washington, DC
•It was given authority to test and improve biological products in 1902 when Congress passed the Biologics Control Act
•This act regulated the vaccines and sera sold via interstate commerce
•That same year, the Hygienic Laboratory added divisions in chemistry, pharmacology, and zoology

National Institutes of Health (NIH):

Federal agency of the Department of Health and Human Services comprising a number of institutes that carry out research and programs related to certain types of diseases, such as cancer

The organization has played a vital role in recent clinical research on the treatment of the following diseases:

•Heart disease and stroke
•Cancer
•Depression andschizophrenia
•Spinal cord injuries

U.S. Public Health Service:

•In 1912, the service, by then called the U. S. Public Health Service, was authorized to study chronic as well as infectious diseases
•In 1930, reorganized under the Randsdell Act, the Hygienic Laboratory became the National Institutes of Health (NIH)
•In 1938, the NIH moved to a large, privately donated estate in Bethesda, Maryland (Starr 1982, 340)

What is the mission of the NIH today?

•Today, the mission of the NIH is to uncover new medical knowledge that can lead to health improvements for everyone
•The NIH accomplishes its mission by conducting and supporting medical research, fostering communication of up-to-date medical information, and training research investigators

The NIH organization has played a vital role in recent clinical research on the treatment of the following diseases:

•Heart disease and stroke
•Cancer
•Depression andschizophrenia
•Spinal cord injuries

Social Security Act of 1935:

•The Great Depression revived the dormant social reform movement in the United States as well as more radical currents in American politics
•Unionization increased, and the American Federation of Labor (AF of L) abandoned its long-standing opposition to social insurance programs
•The Depression also brought to power a Democratic administration
•The administration of Franklin D. Roosevelt was more willing than any previous administration to involve the federal government in the management of economic and social welfare

Social Security Act and FDR:

•Even before Roosevelt took office in 1933, a steady movement toward some sort of social insurance program had been growing
•By 1931, nine states had passed legislation creating old-age pension programs
•As governor of New York State, Roosevelt endorsed unemployment insurance in 1930

Who was the first state to adopt unemployment insurance?

•Wisconsin became the first state to adopt such a measure early in 1932

Roosevelt, unemployment insurance and the committee on economic security:

•Although old-age pension and unemployment insurance bills were introduced into Congress soon after his election, Roosevelt refused to give them his strong support
•Instead, he created a program of his own
•On June 8, 1934, he announced that he would appoint a committee on economic security to study the issue comprehensively and report to Congress in January 1935
•The committee consisted of four members of the cabinet and the federal relief administrator. It was headed by the secretary of labor, Frances Perkins

Committee on economic security: what did the committee include that was not addressed in Roosevelt's message?

Although Roosevelt indicated in his June message that he was especially interested in old-age and unemployment programs, the committee included medical care and health insurance in its research.

In the outset, what was the prevailing sentiment on the committee?

•Was that health insurance would have to wait
•Abraham Epstein was the founder of the American Association for Social Security and a leading figure in the social insurance movement
•In an article published in October 1934, he warned the administration that opposition to health insurance was strong.

Abraham Epstein was the founder of the American Association for Social Security and a leading figure in the social insurance movement, what did he advise?

•He advised the administration to be politically realistic and go slow on health insurance.
•Sentiment in favor of health insurance was strong among members of the Committee on Economic Security
•However, many members of the committee were convinced that adding a health insurance amendment would spell defeat for the entire Social Security legislation
•Ultimately, the Social Security bill included only one reference to health insurance as a subject that the new Social Security Board might study
•The Social Security Act was passed in 1935

What were the Social Security Acts conservative features?

•The omission of health insurance from the legislation
•It relied on a regressive tax and gave no coverage to some of the nation's poorest people, such as farmers and domestic workers
•However, the act did extend the federal government's role in public health through several provisions unrelated to social insurance
•It gave the states funds on a matching basis for maternal and infant care, rehabilitation of crippled children, general public health work, and aid for dependent children under the age of 16

Hospital Survey and Construction Act of 1946:

•Passage of the Hill-Burton Act was another important development in American healthcare delivery
•Enacted in 1946 as the Hospital Survey and Construction Act, this legislation authorized grants for states to construct new hospitals and, later, to modernize old ones
•The fund expansion of the hospital system was to achieve a goal for 4.5 beds per 1,000 persons

Hill-Burton Act:

The federal legislation enacted in 1946 as the Hospital Survey and Construction Act to authorize grants for states to construct new hospitals and, later, to modernize old ones

What created a boom in hospital construction during the 1950s?

•The availability of federal financing created a boom in hospital construction during the 1950s
•The hospital system grew from 6,000 hospitals in 1946 to a high of approximately 7,200 acute care hospitals

Growth in Number of Hospitals

•The number of hospitals in the United States increased from 178 in 1873 to 4,300 in 1909
•In 1946, at the close of the Second World War, there were 6,000 American hospitals, with 3.2 beds available for every 1,000 persons
•In 2002, there were 4,927 hospitals in the United States, with a total of 821,000 beds. Of the $1.4 trillion spent on healthcare in 2001, hospital costs totaled $415 billion, or 32 percent
•Most U. S. hospitals are nonprofit or owned by local, state, or federal governments

Decline in Number of Hospitals: what caused procedures to move outpatient?

•During the 1980s, medical advances and cost-containment measures caused many procedures that once required inpatient hospitalization to be performed on an outpatient basis
•Outpatient hospital visits increased by 40 percent with a resultant decrease in hospital admissions
•Fewer patient admissions and shortened lengths of stay (LOS) resulted in a significant reduction in the number of hospitals and hospital beds

Healthcare reform efforts and the acceptance of managed care as the major medical practice style of U. S. healthcare resulted in:

Enough hospital closings and mergers to reduce the number of government and community-based hospitals in the United States to approximately 5,000 (Sultz and Young 2004, 68).

The advent of diagnosis-related groups (DRGs)

In the mid-1980s resulted in the closure of many rural healthcare facilities

Public Law 89-97 of 1965

•In 1965, passage of a number of amendments to the Social Security Act brought Medicare and Medicaid into existence
•The two programs have greatly changed how healthcare organizations are reimbursed
•Recent attempts to curtail Medicare/Medicaid spending continue to affect healthcare organizations.

Medicare (Title XVIII of the Social Security Act)

•A federal program that provides healthcare benefits for people 65 years old and older who are covered by Social Security
•The program was inaugurated on July 1, 1966
•Over the years, amendments have extended coverage to individuals who are not covered by Social Security but are willing to pay a premium for coverage, to the disabled, and to those suffering from end-stage renal disease (ESRD).

The companion program, Medicaid, Title XIX of the Social Security Act:

•Was established at the same time to support medical and hospital care for persons classified as medically indigent
•Originally targeted recipients of public assistance (primarily single-parent families and the aged, blind, and disabled)
•Medicaid has expanded to additional groups so that it now targets poor children, the disabled, pregnant women, and very poor adults (including 65 and over)

The only exception to the medicaid expansions:

Was passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Public law 104-193), which changed eligibility for legal/illegal immigrants

Today, Medicaid is a federally mandated program that provides healthcare benefits to low-income people and their children. Who administers medicaid, and how did it work?

•Medicaid programs are administered and partially paid for by individual states
•Medicaid is an umbrella for 50 different state programs designed specifically to serve the poor
•Beginning in January 1967, Medicaid provided federal funds to states on a cost-sharing basis to ensure that welfare recipients would be guaranteed medical services

For Medicare, coverage of four types of care was required:

•Inpatient and outpatient services
•Other laboratory and x-ray services
•Physician services, and
•Nursing facility care for persons over 21 years of age

Many enhancements have been made in the years since Medicaid was enacted.

•Services now include family planning and 31 other optional services such as prescription drugs and dental services
•With few exceptions, recipients of cash assistance are automatically eligible for Medicaid
•Medicaid also pays the Medicare premium, deductible, and coinsurance costs for some low-income Medicare beneficiaries

How many people are enrolled in medicaid?

•Four million individuals were enrolled in Medicaid in 1966, its first year of implementation
•By 2006, 54 million people were enrolled in Medicaid programs
•In 2007, the states and the federal government expended $319.6 billion on Medicaid
•Elderly and disabled participants comprised about 65% of the expenditures (Kaiser Family Foundation 2009).

Extended care facility:

A healthcare facility licensed by applicable state or local law to offer room and board, skilled nursing by a full-time registered nurse, intermediate care, or a combination of levels on a 24-hour basis over a long period of time

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