Health care in the United States



Health care in the United States



Learning outcomes


After studying this chapter, students will be able to:


• Describe the four basic categories of services provided by the health care delivery system.


• Describe the shared governance model and explain its use in nursing.


• Describe the relationship between cost-containment and quality management initiatives.


• Relate two major mechanisms used to maintain quality in health care agencies.


• Explain how disparities in health care disproportionately impact minority and poor populations.


• Identify the key members of the interdisciplinary health care team and explain what each contributes.


• Discuss seven primary roles of nurses in the health care delivery system.


• Differentiate among five nursing care delivery systems in use today.


• Explain the economic principles of supply and demand, free-market economies, and price sensitivity and discuss their relevance to health care costs.


• Explain cost-containment efforts and their effect on nursing practice.


• Describe current methods of payment for health care.


• Discuss the role of nurses in managing costs.


• Discuss universal health care as an outcome of health care reform.


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To enhance your understanding of this chapter, try the Student Exercises on the Evolve site at http://evolve. elsevier.com/Black/professional.




Today’s health care system


Debate about health care reform has been a hot topic in American life in the past several years. It is a polarizing issue, and its complexities and detail cause misunderstanding and confusion. In a manner of speaking, this debate mirrors the system of health in place in the United States today.


Chapter opening photo from Photos.com.


The term “health care system” as it is used in the United States is something of a misnomer. Far from providing health care, our system has traditionally provided illness care, focusing on treating health problems once they have occurred rather than encouraging disease prevention through healthy living. The complexity of the system, with multiple types of financing and many different settings where patients can receive services, has resulted in a fragmented system that is difficult to understand and navigate. Although this country has the latest health care technologies, highly sophisticated procedures, and well-educated health care providers, many people do not have access to basic care and even fewer to health promotion and maintenance services.


The U.S. federal government has yet to devise a definitive national health policy. A first step, however, has been taken. In 1979, the federal government initiated the Healthy People program, a science-based program that sets forth, every 10 years, national objectives focusing on health promotion and disease prevention. Every decade Healthy People sets and monitors national health objectives, building on lessons learned in the previous decade. Input is sought from both experts and the general public through a collaborative process. The Healthy People campaign was instituted in the late 1990s to establish health benchmarks and monitor progress toward these benchmarks. The intention was to encourage collaborations across communities and sectors; empower persons to make informed health decisions; and measure the impact of prevention activities (www.healthypeople.gov). The overarching goals for Healthy People 2020 are shown in Figure 14-1.


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FIG 14-1 Healthy People 2020 Framework. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Available at www.healthypeople.gov.

The Healthy People initiative encourages individuals, agencies, communities, and states to participate in its programs, but it does not mandate change in the health care system. For significant change to occur, health care reform will have to come from the national level and be mandatory. The passage of the State Children’s Health Insurance Program (SCHIP) reauthorization legislation in 2009 and the Affordable Care Act (ACA) were crucial steps to improve access to health insurance coverage for most Americans.


Despite the continuing debate on health care reform, you are likely to enter the nursing workforce with much of the current system still in place. This chapter will give you basic information about the way health (and illness) care in the United States is delivered and nursing’s role within this system; health care finance is also addressed.



Major categories of health care services


Four major categories of health services make up the current system: (1) health promotion and maintenance, including early detection; (2) illness prevention; (3) diagnosis and treatment; and (4) rehabilitation and long-term care. Even though these services are provided in a wide variety of settings, virtually all care falls into one of these four categories.



Health promotion and maintenance

Health promotion and maintenance services assist patients to remain healthy, prevent diseases and injuries, detect diseases early, and promote healthier lifestyles. These services require patients’ active participation and cannot be performed solely by health care providers. Health promotion and maintenance services are based on the assumption that patients who adopt healthy lifestyles are likely to avoid lifestyle-related diseases, such as heart attacks, lung cancers, and certain infections.


An example of health promotion and maintenance services is prenatal classes. By learning good nutritional and weight management habits, an expectant mother can take better care of herself and her baby during pregnancy and after the birth. This increases the chances of a normal pregnancy and the birth of a healthy, full-term infant. Other examples of health promotion and maintenance include education about aerobic exercise and safe, responsible sexual activity.


Health promotion also includes the detection of warning signs indicating the presence of a disease in early stages. Early detection allows treatment to be minimal and less costly and fosters positive treatment outcomes. An example of early detection is breast self-examination and mammography, both aimed at detecting breast cancer in its early stages, thereby providing a better chance for successful treatment.



Illness prevention

With the increasing ability to identify risk factors, such as a family history of disease and genetic predispositions, illness prevention services are now better able to assist patients in reducing the impact of those risk factors on their health and well-being. These services require the patient’s active participation.


Prevention services differ from health promotion services in that they address health problems after risk factors are identified, whereas health promotion services seek to prevent development of risk factors. For example, a health promotion program might teach the detrimental effects of alcohol and drugs on health to prevent individuals from using alcohol and drugs. Illness prevention services are used when the patient has been abusing alcohol or drugs and is at risk for developing conditions related to using these substances. The boundaries between health promotion and maintenance, early detection, and illness prevention are often blurred. Box 14-1 gives examples of activities in these three areas.



BOX 14-1   EXAMPLES OF HEALTH PROMOTION AND MAINTENANCE, EARLY DETECTION, AND ILLNESS PREVENTION ACTIVITIES


Health promotion/maintenance







Diagnosis and treatment

Traditionally, in the U.S. health care system, heavy emphasis has been put on diagnosis and treatment. Modern technology has enabled the medical profession to refine methods of diagnosing illnesses and disorders and to treat them more effectively than in the past. Scientific advances permit many noninvasive tests and treatments to be performed. For instance, imaging has become important in diagnosing and following the size and location of solid tumor cancers through sophisticated combinations of positron emission tomography (PET) and computed tomography (CT) images. In addition, three-dimensional (3-D) ultrasonography creates 3-D images of various organs and structures, including fetal development. The future promises more noninvasive visual technologies.


Minimally invasive surgery techniques have transformed surgical procedures, allowing incisions of an inch or less. This technology has reduced postoperative pain; reduced hospital stays from days to hours, thereby reducing costs; and enabled patients to return to normal function much more rapidly.


Unfortunately, high-tech services can lead patients to feel dehumanized. This occurs when caregivers focus on machines and techniques rather than on patients. Even in high-tech settings, nurses must remember that patients benefit most when they understand their diagnoses and treatments and can be active participants in the development and implementation of their own treatment plans—in other words, when care is patient-centered.



Rehabilitation and long-term care

Rehabilitation services help restore the patient to the fullest possible level of function and independence after injury or illness. Rehabilitation programs also deal with conditions that leave patients with less than full functioning, such as strokes or severe burns. Both patients and their families must be active participants in this care if it is to be successful. Rehabilitation services should begin as soon as the patient’s condition has stabilized after an injury or illness. These services may be provided in institutional settings such as hospitals, in special rehabilitation facilities, in long-term care facilities such as nursing homes, or in the home and the community. The objectives of rehabilitation are to assist patients to achieve their full potential and return to a level of functioning that permits them to be contributing members of society.


Rehabilitation services also include disease management services. Disease management services deal with chronic diseases, such as congestive heart failure and diabetes, and ongoing conditions, such as low back pain and hypertension, that contribute to higher health care costs and a reduced quality of life, particularly for aging populations. Disease management programs focus on helping participants understand and manage their chronic conditions more effectively through phone calls or emails, coaching and education, symptom prevention and management, and collaboration with their providers. These steps give providers information between office visits so that they can actively manage the participant’s condition before emergency or hospital services are required, thus reducing health care costs and improving the quality of life for their patients.


Long-term care is provided in residential facilities such as assisted-living homes, skilled and intermediate nursing homes, and personal care homes. Each facility is tailored to provide services that the patient or family cannot provide but at levels that maintain the individual’s independence as long as possible. With the aging of the population, and with more patients surviving severe trauma and disease with impairments in physical or mental functioning or both, long-term care facilities are expected to experience continuing growth.



Classifications of health care agencies


There are many agencies involved in the total health care delivery system. Organizations that deliver care can be classified in three major ways: as governmental or voluntary agencies; as not-for-profit or for-profit agencies; or by the level of health care services they provide.



Governmental (public) agencies

Many governmental (public) agencies contribute to the health and well-being of U.S. citizens. All of these public agencies are primarily supported by taxes, administered by elected or appointed officials, and tailored to the needs of the public.



Federal agencies.

Federal agencies focus on the health of all U.S. citizens. They promote and conduct health and illness research, provide funding to train health care workers, and assist communities in planning health care services. They also develop health programs and services and provide financial and personnel support to staff them. Federal agencies establish standards of practice and safety for health care workers and conduct national health education programs on subjects such as the benefits of not smoking, the prevention of acquired immunodeficiency syndrome (AIDS), and the need for prenatal care. Examples of federal agencies are the National Institutes of Health, the U.S. Department of Health and Human Services, the Occupational Safety and Health Administration, the Centers for Medicare & Medicaid Services (CMS), and the Centers for Disease Control and Prevention.





Voluntary (private) agencies and non-governmental organizations

Citizens often voluntarily support agencies working to promote or restore health. When private volunteers support an agency providing health care, it is called a voluntary (private) agency. Support is generally through private donations, although many of these agencies apply for governmental grants to support some of their activities.


Voluntary agencies often begin when a group of individuals bands together to address a health problem. Volunteers may initially perform all their services. Later, they may obtain enough donations to hire personnel, staff an office, and expand services. They may be able to secure ongoing funding through grants or organizations such as the United Way. Examples of voluntary health agencies are the American Heart Association, the American Cancer Society, the American Red Cross, and the March of Dimes.


A non-governmental organization (NGO) is an association of citizens that operates independently of the government with the goal to deliver resources or serve a social or political purpose. Much of the focus of health-related NGOs is international and involves the delivery of direct health care, providing drinkable water, mitigating endemic diseases such as malaria, and improving nutrition, among other highly significant causes. Médecins Sans Frontières (Doctors Without Borders) is a well-known NGO, as is the International Committee of the Red Cross, Oxfam, Project Hope, and Save the Children.



Not-for-profit or for-profit agencies

The second major way to classify health service delivery agencies is by what is done with the income earned by the agency. A not-for-profit agency is one that uses profits to pay personnel, improve services, advertise services, provide educational programs, or otherwise contribute to the mission of the agency. A common misconception is that not-for-profit agencies do not ever make a profit. Actually, they may make profits, but the profits must be used to further the mission of the agency. Most voluntary agencies, such as the ones listed previously, are also not-for-profit agencies, as are many hospitals.


For-profit agencies distribute profits earned to partners or shareholders. The growth in for-profit health care agencies has risen over the past several decades because of the potential for health care to be very profitable.


For-profit agencies include numerous home health care companies that send nurses and other health personnel to care for patients at home. Several large national chains of for-profit health care providers also exist and have demonstrated that it is possible to provide quality patient care and make a profit while doing so. Examples include national nursing home networks, specialty outpatient centers for ambulatory surgery, heart hospitals, and rehabilitation centers. A controversial issue related to for-profit health care organizations is that they might not treat nonpaying patients. These people must go to publicly funded facilities that are overburdened with patients who are unable to afford expensive health care.



Level of health care services provided

The third way in which health care services can be classified is by the level of health care services they provide. These levels have traditionally been termed primary care, secondary care, and tertiary care. A new level—subacute care—has emerged. These four levels are discussed below.



Primary care services.

Care rendered at the point at which a patient first enters the health care system is considered primary care. This care may be provided in student health clinics, community health centers, emergency departments, physicians’ offices, nurse practitioners’ clinics, or health clinics at worksites. The major goals of the primary health care system are providing the following:



In addition to treating common health problems, primary care centers are, for many citizens, where much of prevention and health promotion takes place. Access to primary care in the least costly setting is now mandated by third-party payers such as insurance companies, the government, and managed care organizations.



Secondary care services.

Secondary care involves the prevention of complications from disease. It includes such activities as treating temporary dysfunctions requiring medical intervention or hospitalization, evaluating long-term care, evaluating patients with chronic illness who may need treatment changes, and providing counseling or therapies that are not available in primary care settings.


Although hospitals have traditionally been associated with this level of care, other agencies increasingly provide secondary health services. They include home health agencies, ambulatory care agencies, skilled nursing agencies, and surgical centers. These settings offer skilled personnel, easy access, convenient parking, compact equipment and monitoring systems, medications and anesthesia services, and a financial reimbursement program that rewards shorter lengths of stay and home or community care.


Disease management is a recent addition to secondary care services. Health services are provided to patients with chronic diseases through outbound/inbound calls with nurses and health professionals, patients’ interactive voice responses (using a touch-tone phone to respond to questions that are entered into an electronic health record), educational videos/books sent to the patient, and Internet-based tools such videoconferencing. To use these services, patients do not have to leave their homes; they have access to health education, coaching, and electronic tools 24 hours a day, 7 days a week. Another advantage is that patients develop a long-term relationship with their disease management nurse or health professional, which improves communication and fosters trust.




Subacute care services.

An additional segment of health care—subacute care services—emerged in the 1990s. Subacute care is defined as inpatient care that lies between hospital care and long-term care. It is goal-oriented, comprehensive inpatient care designed for an individual who has had an acute illness, injury, or exacerbation of a disease process. In general, the condition of an individual receiving subacute care is less complex and does not depend heavily on high-technology monitoring or complex diagnostic procedures. The goal of subacute services is to provide lower-cost health care and create a seamless transition for patients moving through the health care system.


Subacute care is generally more intensive than skilled nursing facility care and less intensive than acute inpatient care. It requires frequent patient assessment and review of the clinical course and treatment plan for a limited time ranging from several days to several months, until a condition is stabilized or a predetermined treatment course is completed.



Organizational structures within health care agencies


The health care delivery system in the United States consists of a variety of agencies such as hospitals, clinics, associations, long-term care facilities, and home health services that provide any of the four major types of health services just discussed. Although the mission, category, and level of health care services provided vary, the organizational structures within them may be similar.



Organizational structure

Organizational structure refers to how an agency is organized to accomplish its mission. The organizational structure of most agencies includes a governing body or board of directors, which may also be called a board of trustees.



Board of directors.

In the past, board members were often chosen from two groups: community philanthropists, who were expected to donate generously to the facility; and physicians, who practiced in the institution. Boards were large, met infrequently, and had mainly ceremonial functions.


As the health care environment became more complex, board members were chosen to represent various business and political interests of the community. They were expected to bring knowledge and expertise from the business world, as well as to have an appreciation and understanding of health care agencies and how they operate.


Boards now carry significant responsibility for the mission of the organization, the quality of services provided, and the financial stability of the organization. Boards are not involved in the day-to-day running of the agency, but they are legally responsible for establishing policies governing operations and for ensuring that the policies are executed. They delegate responsibility for running the agency to the chief executive officer (CEO). Boards of directors may or may not be paid for their services. Box 14-2 is a list of the primary responsibilities of the board of directors of a not-for-profit health care provider (e.g., hospital; hospice).



BOX 14-2   BOARD OF DIRECTORS RESPONSIBILITIES (NOT-FOR-PROFIT ORGANIZATIONS)




From www.boardofdirectorsresponsibilities.org.



Chief executive officer.

The chief executive officer (CEO) is the individual responsible for the overall daily operation. He or she usually has a minimum of a master’s degree in business or hospital administration. Responsibilities include making sure that the institution runs efficiently and is cost-effective and carrying out policies established by the board. The CEO also has an important external role addressing health care issues in the community and usually sits on the board of directors, as well as reports to it. A chief operating officer (COO) often assists the CEO in larger organizations.


Nurses with advanced degrees and experience in administration, business, and health care policy increasingly occupy both CEO and COO positions. Boards, who are responsible for hiring CEOs, have found that the broad holistic education and clinical experience of nurses prepares them well for these positions.



Medical staff.

A medical staff consists of physicians, who may be either employees of the health care organization or independent practitioners. In either case, they must be granted privileges by the board of directors to care for patients at that particular institution. They cannot simply decide to admit patients to an institution. A credentials committee, composed of members of the medical staff, performs the credentialing process. This committee is charged with the responsibility of assuring the board of directors that every physician admitted to the medical staff of that facility is a qualified and competent practitioner and that, over time, each one keeps his or her skills and knowledge updated.


In large medical centers associated with university schools of medicine, the medical staff may include house staff, that is, intern and resident physicians in their first years post-medical school. Physician residencies are 3 to 4 years and are sometimes followed by fellowships that provide additional training in a specific field such as maternal-fetal medicine, neonatology, and pediatric surgery. Residents and fellows provide much of the hour-to-hour medical care of patients hospitalized in these settings; attending physicians make rounds with the residents and fellows usually once a day.


The medical staff, through its credentials committee, is also charged with the responsibility for credentialing providers such as advanced practice nurses, psychologists, optometrists, podiatrists, and others who admit or consult with patients.



Medical staff governance.

In large organizations, medical staffs are usually organized by service (e.g., department of surgery, department of medicine, department of obstetrics). The entire medical staff usually elects a chief of staff. The chief of staff and the chiefs of the various services work together with the CEO and other administrative representatives through the medical executive committee to make important decisions about medical policy and physician discipline for the institution. The rules and regulations that govern these activities are called bylaws. The board of directors, to which the physicians are responsible, must officially approve the credentialing and disciplinary actions of the medical staff.


Service on committees and leadership positions of the medical staff are time-consuming activities; therefore, some institutions pay members of the medical staff a fee for special services in recognition that time away from seeing patients reduces their income.



Nursing staff.

The senior administrative nurse in an organization is known as the chief nurse executive (CNE) or chief nursing officer (CNO), vice president for nursing, or director of nursing. Once excluded from broad institutional decision making, nurse executives today are often members of the board of directors. Progressive organizations now recognize that the CNE and the chief of the medical staff are of equal importance, and this is reflected in their organizational charts.


The educational preparation of CNEs usually includes a minimum of a master’s degree in nursing, business, or health administration. Some nurse executives hold joint master of science in nursing and master of business administration (MSN/MBA) degrees or joint master of science in health and business administration (MHA/MBA) degrees.


CNEs are responsible for overseeing all the nursing care provided in the institution and serve as clinical leaders and administrators. Because of the need to coordinate patient care and outcomes among all disciplines, the role may also include administrative responsibilities for departments other than nursing, such as surgery, pharmacy, respiratory therapy, and social services, among others.


The nursing staff consists of all the registered nurses (RNs), licensed practical nurses/licensed vocational nurses (LPN/LVNs), unlicensed assistive personnel (UAP), and clerical assistants employed by the department of nursing. These staff members are usually organized according to the units on which they work.


Each patient care unit has its own budget and staff, for which the unit manager is responsible. The manager, who is usually a nurse, is also a communication link between the staff and the next level of management.


In large or networked organizations, there may be an additional level of management between the nurse executive and the manager of a unit. These are middle managers, known as clinical directors or supervisors. In most cases, they are also nurses, but they may come from other clinical disciplines or from a business background. These directors are responsible for multiple units or for specific projects or programs. They ensure that nursing and all other services they manage are integrated with other hospital services. They also serve as the communication link between the unit managers and the executive staff.


Other nurses combine direct patient care responsibilities with research, education, and management responsibilities, such as nurse educators, nurse researchers, clinical nurse specialists, and infection control nurses. Nurses in these roles support direct care nurses and serve as expert resources to them in their areas of specialization.



Nursing organization governance.

In most health care agencies, nurses have a nursing staff organization. In some settings, this organization serves mainly as a communication vehicle. In other more progressive settings, nurses govern themselves through the organization, much as the medical staff is expected to govern itself through the medical staff organization.


The concept of shared governance is founded on the philosophy that employees have both a right and a responsibility to govern their own work and time within a financially secure, patient-centered system. Shared governance promotes decentralization and participation at all levels of nursing. In shared governance, the role of the clinical nursing staff is to be responsible for the professional practice of their nursing unit by adhering to standards and benchmarks of quality care (Davis, 2008). The role of the nurse manager and other nurse leaders is to set expectations, facilitate, coordinate, support, and create partnerships with the staff in achieving the identified goals. An example of shared governance is self-scheduling, in which staff members determine their own schedules based on established guidelines for staffing the unit set forth by the manager. The shared governance model promotes improved patient outcomes and enhanced nurse job satisfaction brought about by increased autonomy.


Health care organizations are complex entities. The way they are organized may vary, but each has an organizational chart that shows its unique structure and explains lines of authority. When considering employment in a health care organization, you can learn a great deal by examining its organizational chart to see how nursing is governed and how it relates to senior management and the board of directors. Figure 14-2 shows an example of a basic health care organizational chart.


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FIG 14-2 This is a simple version of an organizational chart showing lines of responsibility in a large health care setting.


Maintaining quality in health care agencies


Providing and maintaining high-quality services are goals of health care agencies. As pressure increases to control costs, it becomes even more important to ensure that quality is not sacrificed to save money. Accreditation and quality care initiatives are two ways this can be achieved.



Accreditation of health care agencies

Health care organizations such as hospitals, home health agencies, and long-term care facilities seek accreditation through one of two accrediting bodies approved by the CMS. They are The Joint Commission, a not-for-profit organization that serves as the nation’s predominant standard-setting and accrediting body in health care (The Joint Commission, 2012), and the Healthcare Facilities Accreditation Program, authorized by the CMS. The goal of accreditation is to improve patient outcomes. Accreditation is important and requires that a number of standards be met in every department. Considerable resources of time and money are spent making sure accreditation criteria, set by these external accrediting bodies, are met.



Continuous quality improvement and total quality management

An additional strategy through which most organizations choose to work internally toward improvement in patient outcomes is continuous quality improvement (CQI).


The concept of CQI was first developed by management expert W. Edwards Deming in the 1940s, when he suggested that managers in industry should rely on groups of employees, which he called quality circles, as they made decisions about how work was to be done. In today’s health care systems, CQI, also called total quality management (TQM), is one of the most important concepts borrowed from industry. Rather than trying to identify mistakes after they have occurred, these systems focus on establishing procedures for ensuring high-quality patient care. Using quality improvement concepts, groups of employees from different departments decide how care will be provided. They decide what outcomes are desired, and they design systems and assign roles and activities to create those outcomes. Every effort is made to anticipate potential problems and prevent their occurrence. Management delegates authority to the providers of services to plan and carry out quality improvement programs. Programs in CQI/TQM reinforce the belief that quality is everyone’s responsibility.


Performance improvement (PI) is another term used to describe organizational efforts to improve corporate performance. Incorporating aspects of quality management, PI focuses efforts on increasing individual and group competence and productivity. Quality can be compromised in the process of increasing productivity, however, and this must be guarded against.


Nurses are actively involved in quality and performance improvement and in accreditation processes, but these activities are not the responsibility of nursing alone. They are institution-wide initiatives, and everyone, at all levels, gets involved. Working together to improve patient care builds cooperation among departments and clinical disciplines and boosts morale.



A continuing challenge: Health care disparities


Health care disparities are differences in access to and the quality of health care provided to different populations. Ethnic or racial disparities receive much attention among those examining health care delivery; however, differences also have been found to exist between the treatment and treatment outcomes of men and women, as well as younger and older people. The causes of disparities may be due to race, ethnicity, gender, age, income, education, disability, sexual orientation, and place of residence (Agency for Healthcare Research and Quality, 2007). Most likely a combination of these and possibly other factors leads to disparities, which have been difficult to reduce despite increasing attention to their significant negative effect on large segments of the population.


Provider bias has been mentioned as a possible contributing factor to health care disparities. For example, a study examining treatment of adults with soft-tissue cancers of an arm or a leg “showed that blacks had the lowest rates of limb-preserving surgeries and the highest rates of amputations in comparison with white, Hispanic, and Asian patients” (Voelker, 2008). This study found that black patients also had the lowest rates of radiation therapy used in conjunction with surgery compared with other groups. This chapter’s Cultural Considerations Challenge contains more information about health care disparities. If this is a topic you wish to learn more about, you will find a continuing education module, “Disparities in Health Care: Focusing Efforts to Eliminate Unequal Burdens” by D. Baldwin in the American Nurses Association (ANA) online journal Online Journal of Issues in Nursing (OJIN). Follow links at the ANA website (www.nursingworld.org).



imageCULTURAL CONSIDERATIONS CHALLENGE


Facts About Health Disparities


The U.S. Department of Health and Human Services’ Office of Minority Health and Health Disparities has selected six focus areas in which racial and ethnic minorities experience serious disparities in health access and outcomes:


1. Infant mortality


African-American, American-Indian, and Puerto Rican infants have higher death rates than white infants. In 2000, the African-American to white ratio in infant mortality was 2.5 (up from 2.4 in 1998). This widening disparity between African-American and white infants is a trend that has persisted over the last two decades.






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Mar 21, 2017 | Posted by in NURSING | Comments Off on Health care in the United States

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