The US Healthcare System The Meat of the U.S. Health Care System: Doctors, Nurses and Hospitals

Healthcare Professionals Healthcare is a major employer It has a rapidly growing labor sector Professionals Non-professionals and technicians Non-institutional workers Rapid growth due to: Technology growth and specialization Health insurance coverage Aging population Emergence of hospitals

Types of Healthcare Worker Certification Licensure – state or legal designation Certification and registration Independent and dependent professions Independents practice without physician supervision (e.g., doctors, dentists) Dependents need physician supervision (most nurses, CNAs)

Physicians Comprised of two types by practice Primary care physicians – short supply in U.S. Family Practice, Internal medicine, OB/GYN, Pediatricians Specialists – Surplus in U.S. Specialize in specific areas

Physician Surplus or Shortage? Rapid growth of physicians, esp. specialists, during due to: Massive federal outlays Influx of International Medical Graduates (IMGs) Maldistribution of physicians can give appearance of shortage Not enough primary care providers Medical underserved areas in rural communities and inner cities Malpractice and the impact on physicians

Changing Role of the Physician More employed physicians By managed care organizations and hospitals (the emergence of the “Hospitalist”) Large group practices emerged with the growth of managed care Emphasis away from specialty areas to managed care More female physicians

Distribution of Physicians by Specialty: 1980, 1986, 1995, 2000 (In thousands Pct. Change SpecialtyNo./% No./% No./% No./% All specialties414/ / / / Primary Care159/ / / / Other Medical Specialties 25/6.2 62/ / / Surgical Specialties110/ / / / All other specialties118/ / / /

Physician Authority Based on modern science and scientific knowledge. Physicians become the intermediaries between science and private experience Authority signifies the presence of status and quality Requires legitimacy and dependence. Legitimacy – acceptance by subordinates Dependence – bad things can happen if we don’t obey Types of Physician Authority Social Authority Cultural Authority Professional Authority

The Evolution of the Physician in the U.S. Allopathic Homeopathy Osteopathic Chiropractic

Physicians Comprised of two types by practice Primary care physicians – short supply in U.S. Family Practice, Internal medicine, OB/GYN, Pediatricians Specialists – Surplus in U.S. Specialize in specific areas

Physician Surplus or Shortage? Rapid growth of physicians, esp. specialists, during due to: Massive federal outlays Influx of International Medical Graduates (IMGs) Distribution of physicians gives appearance of shortage Not enough primary care providers Medical underserved areas in rural communities and inner cities Malpractice and the impact on physicians

Physicians: NV vs. US Physicians TypeNevadaU.S. Generalists/100,000 pop.2130 Specialists/100,000 pop

Changing Role of the Physician More employed physicians By managed care organizations and hospitals (the emergence of the “Hospitalist”) Large group practices emerged with the growth of managed care Emphasis away from specialty areas to managed care More female physicians

Physicians who would recommend the practice of medicine

For physicians who wouldn’t recommend medical profession

Distribution of Physicians by Specialty: 1980, 1986, 1995, 2000 (In thousands Pct. Change SpecialtyNo./% No./% No./% No./% All specialties414/ / / / Primary Care159/ / / / Other Medical Specialties 25/6.2 62/ / / Surgical Specialties110/ / / / All other specialties118/ / / /

Physician Medical Education Undergraduate medical curriculum Most emphasize the acute care setting Increase in women and minorities Graduate medical education Major increases in residencies Shifts in the organization of medical schools Must compete for patients Shift to managed care by med school hospitals Trends medical education in for-profit hospitals Flexnor Report

Patient Visits per 100 persons by Ambulatory Service Type, and

Nurses Typifies the concern of healthcare: “nursing is concerned with human response to health problems” Historic factors that shaped nursing as a career: Occupation to support physicians Emergence of hospitals as community institutions Acceptable female occupations, primarily white females Linked to religious orders

Understanding the Nursing Shortage Changes in occupational opportunities for women since 1970s Majority of RNs are 50+ years of age or married with children at home Low salaries – pay compression Burnout Lack of clinical career ladder Active vs. Inactive – about 1/3 of nurses not working fulltime

The Nursing Shortage Snapshot Estimated shortfall of 1.1 million RNs in U.S. by 2012 Demand requires at least 110,000 more nursing graduates/year. Shortage of nurse faculty: enrollment up by 13% in 2005, but more than 36,000 qualified applicants turned away. Some Solutions? Improve work environment conducive to recruiting new nursing faculty and retaining nurse educators Increase amount of public and private funding for nursing programs Implement new methods of instruction. Improve partnerships between nursing schools and clinical sites Is importing nurses a solution?

Hospitals The growth of Hospitals in the U.S. is a fairly recent history: Hill-Burton Hospital Insurance Advances in medical science Professional nursing Improved medical school training for physicians Cost containment practices have lowered hospital utilization Decreased inpatient utilization through DRGs and managed care Shift to outpatient services System and specialty hospital growth

Hospital Classification For-profits – fastest growing type of hospitals For-profit and non-profit systems (e.g., Kaiser Permanente, Catholic Hospitals West) Public Hospitals Numbers are in decline Serve disproportionate number of Medicaid and uninsured Account for nearly 25% of uncompensated care Includes federally funded facilities such as VA and Armed Services facilities (McCallahan Federal Hospital)

Hospitals (types cont.) Academic teaching hospitals Tripartite mission Face shaky future Rural Hospitals Small, non-profit Many with nursing home swing beds Endangered Quality of care in question Types of services available being lost to cities

Number of Public Community Hospitals, U.S.

Constraining and Propelling Forces Affecting Hospital Constraining Governmental and third party purchaser pressure for cost containment Competition from multi-hospital systems and local physicians Conservatism of some traditionally oriented practicing physicians Cost of continuing technological advances Slower growth of the economy Changing governmental philosophy toward health care Propelling New health markets other than inpatient care Weakening power of physicians in the hospital New organizational structures Increasing power of a more business-oriented management team Aging of the population Changing customer expectations for service

Hospital Beds per 1,000 population by Ownership, 2002 NevadaU.S. State/Local Government Hospital Beds 17%16% Non-Profit Hospital Beds 32%71% For Profit Hospital Beds 51%13%

Background: Las Vegas Hospitals September, 2001 TotalGovt. (n=2) Private, For-Profit (n=6) Private, Non-Profit (n=3) Number of Hospital Beds Number of ER Beds Isolation Beds ER Clinicians Security Staff

Percent Distribution of Mental Health 24-hour hospital and residential treatment beds

Who Gets Treatment for Mental Illness?

Ambulatory Care Personal health care given to the patient in an non-hospital or institutional setting Types of settings: Physician owned private practice Managed care clinic settings Community health care settings “Urgent care” facilities Shift to ambulatory care due to several factors: Medicare PPS Managed care Improved technology

Patient Visits per 100 persons by Ambulatory Service Type, and