1. Introduction to Healthcare and
Public Health in the US
Introduction and History of
Modern Healthcare in the US
Lecture a
This material (Comp1_Unit1a) was developed by Oregon Health and Science University, funded by the Department of Health
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IU24OC000015.
2. Introduction and History of Modern
Healthcare in the US
Learning Objectives
• Delineate key definitions in the healthcare domain
(Lectures a, b, c, d)
• Explore components of healthcare delivery and
healthcare systems (Lecture a)
• Define public health and review examples of
improvements in public health (Lecture b)
• Discuss core values and paradigm shifts in US
healthcare (Lecture c)
• Describe in overview terms, the technology used in the
delivery and administration of healthcare (Lecture d)
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3. Some Definitions: Health
• Health – often thought of as the absence of
disease
• World Health Organization (WHO) - specialized
agency of the United Nations definition: Health is
defined as the “…state of complete physical,
mental and social well-being and not merely the
absence of disease or infirmity”
• Thus “illness” is a state of poor health
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4. Healthcare
• Healthcare is the prevention and treatment of illness
• Healthcare is delivered by different people from different
disciplines, including
– Medicine
– Dentistry
– Nursing
– Laboratory Science
– Pharmacy
– Other allied health professions
• These people come together as interdisciplinary teams
to deliver care
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5. Healthcare Delivery
• Healthcare is delivered in different places
• Inpatient facilities
– Hospitals
• Institutions for treating sick or injured people
• Historically places for shelter, almshouses
• Hospital Survey and Construction Act (also known
as the Hill-Burton Act) passed in 1946 that
provided federal grants to improve hospital
physical infrastructure
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6. Healthcare Delivery (continued)
• Inpatient facilities
– Different types of hospitals
• General medical and surgical hospitals
• Specialty hospitals (orthopedic, pediatrics,
women’s services)
• Psychiatric hospitals
• Hospitals may be publicly or privately owned
• Patients can be admitted to a hospital through the
emergency room, or directly admitted from a physician’s
office
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7. Healthcare Delivery (continued)
• Nursing and residential care facilities
– Can be short term facilities or long term
facilities
– Long term care classified by level of care
– Nursing homes initially proliferated after an
amendment of the Social Security Act and
gradually shifted from being part of the
welfare system to being a part of the
healthcare system
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8. Healthcare Delivery (continued)
• Nursing and residential care facilities
– In 1969, "Intermediary Letter 371" drastically reduced
coverage for nursing homes
– In 1970, the Miller Amendment established a new
standard - "intermediate-care” facilities
– In the 1990s another standard was defined: “subacute
care” – that provided care for patients discharged
from hospitals who briefly need a higher level of care
“than is provided to the majority of patients in a skilled
nursing facility”.
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9. Healthcare Delivery (continued)
• Outpatient facilities
– Physicians offices
• Primary care offices
• Specialty care offices
• Single specialty or multispecialty offices
– Dental offices
• General dentists or specialists
– Medical and diagnostic laboratories
– Other ambulatory health services
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10. The Healthcare Industry
• The healthcare industry is one of the largest industries in
the US
• In 2008 – 14.3 million jobs for wage and salary workers
• Industry comprises of 595,800 establishments
– about 76 percent of healthcare establishments are
offices of physicians, dentists, or other health
practitioners.
– although hospitals constitute only 1 percent of all
healthcare establishments, they employ 35 percent of
all healthcare workers
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11. Organization of the Healthcare Industry
Industry segment Employment Establishments
Total 100.0 100.0
Ambulatory healthcare services 42.6 87.3
Offices of physicians 17.0 36.0
Home healthcare services 7.2 3.7
Offices of dentists 6.2 20.4
Offices of other health practitioners 4.7 19.6
Outpatient care centers 4.0 3.6
Other ambulatory healthcare services 1.8 1.4
Medical and diagnostic laboratories 1.6 2.4
Hospitals 34.6 1.3
General medical and surgical hospitals 32.5 1.0
Other specialty hospitals 1.4 0.2
Psychiatric and substance abuse hospitals 0.7 0.1
Nursing and residential care facilities 22.8 11.4
Community care facilities for the elderly 5.2 3.5
Residential mental health facilities 4.1 4.0
Other residential care facilities 1.3 1.1
1.1 Table: Percent distribution of employment and establishments in health services by detailed industry sector, 2008.
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12. Healthcare Systems
• A healthcare system is an organization
that delivers healthcare
• Many variations and iterations of
healthcare systems worldwide, but in
general, healthcare systems
– promote good health in populations
– balance the levels of actual care
provided with the expectations of the
population they serve
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13. Healthcare Systems (continued)
• Different models of healthcare systems
– Purely public (care conducted by the state)
– Purely private (care conducted by
independent, privately funded organizations)
– Often a mixed model
• In countries with state run healthcare
system, a private system may coexist in
parallel or offer services not available
under the public system
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14. Healthcare Systems (continued)
• There is no universal healthcare system in the
US
• But there are public and private components
• Public healthcare systems may be organized:
– At the federal level (for example, the Veterans
Health Administration)
– As a partnership between federal and state
governments (such as Medicaid and the
Children’s Health Insurance Program)
– At the local level
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15. Healthcare Systems (continued)
• Privately owned, commercial organizations may
also act as healthcare systems
• These organizations may serve a single area or
multiple geographic locations
• Private healthcare systems may be:
– Not-for-profit organizations (governed by
principle of non-distribution) or
– For profit organizations (distribute surplus
funds to shareholders or owners)
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16. Healthcare Systems (continued)
• Healthcare systems can be measured
using benchmarks
– One framework for assessment:
• Patient assessed value
• Performance on clinical interventions
• Efficiency
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17. Introduction and History of Modern
Healthcare in the US
Summary – Lecture a
• Important definitions:
– Health – not just the absence of disease or illness
– Healthcare – prevention and treatment of illness
– Healthcare System – an organization that delivers healthcare
• There are different types of healthcare delivery:
– Inpatient (hospitals, short and long term care facilities)
– Outpatient (speciality care facilities, laboratories)
• There are different healthcare system models that range from
private to public funding; most systems fall somewhere between
these two extremes.
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18. Introduction and History of Modern
Healthcare in the US
References – Lecture a
References
• 2002 NAICS Definitions - 621 Ambulatory Health Care Services. (2002). Retrieved December 6, 2011, from US
Census Bureau website: http://www.census.gov/epcd/naics02/def/NDEF621.HTM.
• Career Guide to Industries, 2010-11 Edition. (2011). Retrieved December 6, 2011, from Bureau of Labor
Statistics, U.S. Department of Labor website: http://www.bls.gov/oco/cg/.
• Definition of Healthcare. Preamble to the Constitution of the World Health Organization as adopted by the
International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the
representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into
force on 7 April 1948.
• Duckett, S. J., & Ward, M. (2008). Developing ‘robust performance benchmarks’ for the next Australian healthcare
Agreement: The need for a new framework. Aust New Zealand Health Policy , 5(1).
• Health Care Careers Directory - Allied Health . (2011). Retrieved December 6, 2011, from American Medical
Association website: http://www.ama-assn.org/ama/pub/education-careers/careers-health-care/directory.shtml.
• Hospital. (2011). In Encyclopædia Britannica. Retrieved from
http://www.britannica.com/EBchecked/topic/272626/hospital .
• Subacute care definition . (2011). Retrieved December 6, 2011, from Ca.gov Department of Healthcare Services
website: http://www.dhcs.ca.gov/provgovpart/Pages/SubacuteCare.aspx.
• World Health Report 2000 - Health systems: improving performance. (2000). Retrieved December 6, 2011, from
WHO website: http://www.who.int/whr/2000/en/.
Charts, Tables, Figures
1.1 Table: BLS Quarterly Census of Employment and Wages, 2008. (2008). Retrieved December 6, 2011, from US
Bureau of Labor Statistics website: http://www.bls.gov/cew/.
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Notes de l'éditeur
Welcome to Introduction to Healthcare and Public Health in the US , An introduction to modern healthcare in the US. This is Lecture a. This unit is part of a component that is a survey of how healthcare and public health are organized and services are delivered in the US.
The Objectives for Introduction and History of Modern Healthcare in the US , are to: Delineate key definitions in the healthcare domain (covered in lectures a, b, c and d) Explore components of healthcare delivery and healthcare systems (covered in lecture a) Define public health and review examples of improvements in public health (covered in lecture b) Discuss core values and paradigm shifts in US healthcare (covered in lecture c), and Describe in overview terms, the technology used in the delivery and administration of healthcare (covered in lecture d)
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 [ hoo ] 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.
Let’s look at the term “healthcare.” Healthcare is the prevention and treatment of illness. It’s 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 [purr- fyoo -zhuhn-ihsts] 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.
Healthcare is delivered in different places. In this unit, we are going to define and look at in-patient facilities, 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. These are physical structures that house patients during treatment, and allow clinicians to conduct diagnostic tests and perform management interventions and also perform 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 Hilburton Act, since it was sponsored by Senator Harold Burton of Ohio and Senator Lister Hill of Alabama. This law provided federal grants to improve hospital physical infrastructure and led to a significant augmentation of the infrastructure of facilities that provided in-patient care in the United States.
And 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 will be evaluated by a team of clinicians. If the clinicians feel that they are sick enough, they may be admitted into the hospital for care. Patients may also be directly admitted to hospitals from physician’s offices.
Let us now turn our attention to healthcare 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. 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 healthcare system.
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 in 1970, the Miller Amendment established a new standard. Intermediate care facilities that didn’t require the same amount of skilled nursing or resources thus required reduced levels of reimbursement. And 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.
Let’s now spend some time talking about healthcare 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 healthcare 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 that 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. When we think of laboratories, we think of medical and diagnostic laboratories. Diagnostic laboratories are typically involved with imaging: x-rays, C-T scans (Computerized Axial Tomography or CAT scan), M-R-Is (Magnetic Resonance Imaging), and mammograms. Ultrasound imaging centers are examples of diagnostic laboratories. Medical laboratories usually deal with biologic specimens such as blood, cytology [sigh- tall -uh-jee] , or bacteriologic specimens. Specialized medical laboratories include D-N-A testing laboratories, medical pathology laboratories, parasitology [pair-uh-sigh- tall -uh-jee] and mycology health laboratories, toxicology health testing, and facilities that deal with non-radiologic, non- x-ray testing services. Examples of ambulatory health services include ambulance services, home healthcare, blood and organ banks, hearing and vision screening facilities, smoking cessation programs, hospice services, and visiting nurse services.
The healthcare industry is one of the largest industries in the US. In 2008, 14.3 million jobs for wage and salary workers came from this industry. The industry comprises of almost 600,000 establishments and about three quarters of these establishments are the offices of physicians, dentists, or other health practitioners in the outpatient setting. It is interesting to note that while hospitals constitute only one percent of all healthcare establishments, they employ thirty-five percent of all healthcare workers.
This table reflects the organization of the healthcare industry and shows the percent distribution of employment in establishments in the health services sector. This data is from 2008. You can see that about eighty-seven percent of establishments and forty-two percent of employment is in the ambulatory healthcare 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 healthcare 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.
So what is a healthcare system? A healthcare system is an organization that delivers healthcare. There are many variations and iterations of healthcare systems worldwide but two general rules apply: healthcare systems promote good health in populations, and healthcare systems balance the levels of actual care provided with the expectations of the population that they serve.
There are different models of healthcare systems. At the one end is a purely public system where care is entirely conducted by the state. On the other end is a purely private healthcare system model where care is conducted entirely by independent privately funded organizations. In reality, healthcare systems often exist in a mixed model that falls somewhere between these two extremes. Even in countries with state run healthcare systems, a private system may co-exist in parallel, and the private system may offer a full spectrum of services, or services that are not available under the public system.
There is no universal healthcare system in the US but there are public and private companies. Public healthcare systems may be organized at the federal level. For example, the Veteran’s Health Administration provides healthcare for veterans through a series of outpatient and inpatient facilities run by the US Department of Veterans Affairs, which is the US government’s second largest department. Public healthcare systems may also exist as a partnership between federal and state governments. Two examples are Medicaid, which is available to some, but not all economically disadvantaged patients, and the Children’s Health Insurance Program, which covers uninsured children. Public healthcare systems may also be organized at the local level, for example, the Multnomah County Health Department, which provides clinical and public health services in Portland, Oregon.
Privately owned commercial organizations may also act as healthcare systems. These organizations may serve a single area or they may serve multiple geographic locations that may be contiguous or disparate. There are two types of private healthcare systems: not-for-profit and for-profit. Not-for-profit organizations do not operate with the intent to make profits for private gain. Generally if not-for-profit organizations do generate a surplus, the profit is used to further the goals of the organization. These organizations are governed by the principle of non-distribution. For-profit organizations distribute surplus funds to shareholders or owners.
Healthcare systems can be measured using benchmarks. An appropriate choice of benchmarks is essential for an accurate evaluation. One framework of assessment that was developed in New Zealand looked at patient assessed value - that is, timeliness, cost to the patient, and the extent to which patients’ expectations are met - and also looked at performance, clinical intervention, and efficiency. Developing robust performance benchmarks is essential in order to understand how healthcare systems function.
This concludes Lecture a, of Introduction and History of Modern Healthcare in the US. In summary, this lecture has defined three important terms - health, healthcare and healthcare systems. There are many different types of healthcare 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, healthcare systems vary greatly from country to country. Most systems are characterized by a combination of public and private funding.
