1. HCA 701: Survey of the U.S. Healthcare System
Introduction to Healthcare Services in the United States

2. RESOURCES NEEDED TO MAINTAIN A HEALTH CARE DELIVERY SYSTEM
Financing
Health Care Delivery System
Technology & Supplies
Healthcare Professionals
Four major factors impact the ability of the healthcare delivery system to operate. The most important is personnel. In healthcare, this includes the obvious players, physicians, nurses, pharmacists, radiologists, technicians at all levels. It is also one of the most critically understaffed of the professions. We used to argue that the U.S. had more physicians that were necessary, and while that may be true in many areas still, we can easily look at the State of Nevada and find that this is not the case. We have fewer general practitioners and specialists per 1,000 population than almost every other state in the country. The shortage of nurses is a crisis in the country, but especially in Southern Nevada. More hospitals are opening in Southern Nevada than any other geographical area, so the shortage has become even more acute here. As we will learn in this course, healthcare personnel are critical to the success of any organized emergency preparedness system.
Facilities are also critical. Even though Southern Nevada is building hospitals at a faster rate than just about every community, we are still under-bedded when compared to the average American city. Potential problems facing the Las Vegas community are exacerbated by the lack of health care resources for an over-expanded population (AARP, 2000). The area grew by more than 500,000 individuals during the last decade. Health care resources are in short supply. There are significantly fewer hospital beds, physicians, nurses, and other health care personnel (AARP, 2000). The county averages less than two hospital beds per 1,000 compared to a national average of 2.8 beds per 1,000. By contrast, New York City averages nearly four beds per 1,000 (Dartmouth Atlas of Health Care, 2000). Hospital emergency rooms in Clark County are on divert nearly the entire year, even during those periods when full capacity would not be expected. New hospitals were built to help accommodate that growth and at least four others are planned, but the human and technological resources needed to serve the growing population have not been able to keep up with demand.
Technology and supplies include the equipment needed to maintain the healthcare system. From an epidemiological point of view, technology is described as devices, procedures and pharmaceuticals. This has been the area where the healthcare system has made its greatest strides.
Financing deals with how healthcare organizations make their money to operate. Since the United States operates with a system of healthcare payment that relies on a multitude of healthcare payers, primarily private payment systems, there has been little discussion to reimbursement strategies for the healthcare delivery system. Other technologically and economically advanced countries have universal access to health care so this will require a healthcare organizations to examine their resources carefully. In addition, expectations by government regulations to address preparedness issues will also raise the question as to who will pay for any needed improvements, especially when the most will view the potential for such an event as unlikely. For example, while it is safe to assume that hospitals in Las Vegas will do all they can, within financial reason, to better prepare for a large-scale event, they must consider the risk of that event in comparison to their other healthcare priorities. Since most of the Vegas area hospitals are privately owned, they also have a responsibility to their stockholders. To expect a large financial investment for something that is unlikely to happen – no matter how much we would like to think we are prepared – is unrealistic. It is difficult to advocate on the one-hand a privately operated and funded health care system, and to expect them to make investments for potential, but rare and unprofitable events. The system will likely need to change before those realizations can be met.
Facilities
Source: Williams and Torrens,
Introduction to Health Services, 2002

3. BASIC SERVICE COMPONENTS OF A HEALTH CARE SYSTEM
Public Health (Including Health Promotion and Disease Prevention)
Emergency medical services (including transportation)
Ambulatory care for simple/limited conditions
Acute and community hospitals and medical centers
Long-term care (either in-home or institutional care)
Mental Health Services (both inpatient and ambulatory)
Rehabilitation services (both inpatient and ambulatory)
Dental services
Pharmaceuticals/supplies/medical devices and equipment
Although each of these are typically separate entities, each is connected in many ways. At the local level, there are public health departments. In most states, these are autonomous county agencies with linkages to State health departments (division in the case of Nevada). Other links with the health department go to the national level with the Centers for Disease Control and Prevention. Further still is an international link through the World Health Organization. In the case of disease outbreaks, for example, information is shared up and down the public health system.
Emergency medical services include those first responders who provide care to the injured or sick. These can be independent emergency responders or they may include Fire Department responders (typically EMTs). One of the main reasons for the decline in deaths from injury is the development of a transport system that includes communication with hospitals to provide patient information and additional treatment.
Ambulatory care includes physician practices and urgent care centers. Moreover, if we have outbreaks in which physicians and urgent cares become the first responders, we also increase the likelihood of further contamination.
We will spend considerable time during the semester discussing the role of hospitals. While patients consider the “term” hospital as all encompassing for inpatient services, some hospitals are more capable than others of providing emergency care. Particularly those that may result with injuries and trauma. In Las Vegas for example, UMC provides level 1 trauma services. But Boulder City Hospital is a community hospital that is limited in the scope of services it provides. It benefits from having close proximity to other larger and better equipped hospitals. Because of its small size and service area, it doubles as a long-term care facility providing nursing home care in half of its beds.
Long-term care is used to describe the care given to patients who need additional rehabilitative services that the hospital is not funded to provide. With the development of the Diagnostic Related Groups (DRGs) during the 1980s, hospitals were forced to limit the number of days and conditions for which they could treat patients. As a result, we have seen the shift of long-term care beyond the traditional nursing home to now include home health services and sub-acute inpatient services. In Las Vegas, facilities such as Harmon Medical Services and Kindred Hospital are considered “sub-acute” facilities. They are not nursing homes, per se, but institutions in which patients needing additional inpatient recovery are referred. In fact, they are licensed as hospitals and are identified by state plans as hospitals facilities. While nursing homes are the traditional model of long term care, their role in emergency preparedness may be limited. However, the sub-acute inpatient facilities have been targeted to play a larger role in emergency preparedness.
Mental Health Services. This is frequently the most over-looked area in healthcare delivery, in part because of the patients with whom they are associated.
Rehabilitation Services. Although limited in the current number of patients they can accept due to size and staff constraints, local sub-acute facilities in Las Vegas have been targeted to accept 100 patients as a result of a spillover of patients due to a large scale emergency.
Dental services are among the most entrepreneurial of the health care systems. That is because
Pharmaceuticals/supplies/medical devices and equipment. Pharmaceuticals have been one of the major drivers in the increase in the cost of health care services. They have also become very controversial for a number of other reasons, not the least is direct to consumer marketing strategies that have placed more emphasis on having patients direct their physicians to prescribe certain drugs rather than having the physicians prescribe the medication based on patient need. This has led to use of some pharmaceuticals such as Vioxxe to be used on patients who would do just fine with other anti-inflammatory drugs. Also, the marketing of new drugs vs. lower cost generics.
Supplies and medical devices will also play a critical role. Healthcare organizations were in short supply of personal protective gear for treating exposed patients, and though that has been addressed through some grants, this is still an issue among hospitals. In addition, hospitals have been increasingly looking to cyber technology for preventing identity theft and to prevent theft of hospital plans, financial information, and patient information.

4. Brief History of the Development of the U. S
Brief History of the Development of the U.S. Health Care System 1850 – World War II
Issues
1850 – 1900
1900 – WWII
Major targets at the time
Epidemics of acute infections related to food, water, housing and other conditions of life
Acute events, trauma, or infections affecting individuals not groups
Technology available
Virtually none
Beginning of rapid growth of basic medical sciences & tech
Social Organization for health care
None; individuals left to their own resources or charity
Societal/governmental efforts begin to care for those who can’t care for themselves
Involvement of people in their health care
People actively involved in giving care to family; little factual knowledge
Medical knowledge begins to take shape in general public

5. Brief History of the Development of the U. S
Brief History of the Development of the U.S. Health Care System WWII - Present
Issues
WW II – 1980
Present
Major targets at the time
Chronic diseases such as heart disease, cancer, stroke
Greater emphasis on chronic diseases, emotional/behavioral issues, occupational and genetic inheritance
Technology available
Explosive growth in medical science; technological takeover
Continued advancement in technology contributing to rapid rise in health care costs
Social Organization for health care
Health insurance becomes primary vehicle for organization of health care
Increasing power of financial organizations; increasing influence of governmental financial systems (Medicare, Medicaid).
Involvement of people in their health care
Health care becomes social and political issue
Well-informed public but confusing complexity of system

6. Life Expectancy at Birth

7. Life Expectancy at Birth and at age 65 years 1900, 1950, and 2000

8. Classification for Health Status Today
Disease – a state of dysfunction of the normal physiological processes manifested as signs, symptoms, and abnormal physical or social function (includes injury).
Functional Ability – a process used to represent how independently an individual can perform or fulfill expected social roles (physical and mental).
Quality of Life – multidimensional concepts of measures covering symptoms/problem complexes, mobility, physical activity, emotional well-being and social functioning.

9. Blum’s Model of Factors Affecting Health
Environment
Fetal
Physical
Socio/Cultural
Lifestyle
Attitudes
Behavior
Biology
Medical Care
Prevention
Cure
Care
Rehabilitative

10. Primary Cause of Death 1997 Source: Healthy People 2010

11. 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

12. 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)

13. 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

14. 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

15. 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

16. Distribution of Physicians by Specialty: 1980, 1986, 1995, 2000 (In thousands
Pct. Change
Specialty No./% No./% No./% No./%
All specialties 414/ / / /
Primary Care 159/ / / /
Other Medical
Specialties 25/ / / /
Surgical Specialties 110/ / / /
All other specialties 118/ / / /

17. Will doctors meet demand in a bio-terror event
Concern has been raised as to how well physicians will respond in the event of a terror outbreak. These issues were raised in light of a 1990 poll that asked doctors if they would treat AIDS patients. Although the good news is that more than 70% of the doctors said that they would, that still leaves a significant number who were unsure or who would not. Given the current shortage of physicians in medically underserved areas in places such as Las Vegas, this could give rise to concerns about meeting the preparedness level.

18. 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

19. 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

20. 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

21. Patient Visits per 100 persons by Ambulatory Service Type, 1993-94 and 1999-2000
As this chart depicts, ambulatory visits are increasing, although emergency department visits continue to rise. This will present unique challenges for emergency preparedness.

22. 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

23. 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)

24. 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

25. Number of Public Community Hospitals, U.S.

26. Constraining and Propelling Forces Affecting Hospital
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

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

28. Background: Las Vegas Hospitals September, 2001
Total
Govt.
(n=2)
Private, For-Profit (n=6)
Private, Non-Profit (n=3)
Number of Hospital Beds
2972
639
1963
370
Number of ER Beds
272 61
161 50
Isolation Beds
166 46 58 62
ER Clinicians
379 95
240 44
Security Staff
136 49 67 20

29. Decontamination Capabilities and Personal Protection Equipment, 2001

30. Hospitals and Emergency Preparedness: Observation Areas and Data Collection

31. Mental Health Services
Definition: Painful emotional symptoms…inability to think, remember or concentrate…increased potential of medical illness, pain, disability or even death
Affects 30% of all adults
Most mental illness is untreated
20-40% of homeless population is suffers from mental illness
Mental illness is a crisis situation for Nevada hospitals

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

33. Who Gets Treatment for Mental Illness?