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The U.S. healthcare system:origins, organization and opportunities

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Provides a diverse, multi-faceted approach to health care evaluation and management


The U.S. Health Care System: Origins, Organization and Opportunities provides a comprehensive introduction and resource for understanding healthcare management in the United States. It brings together the many “moving parts” of this large and varied system to provide both a bird’s-eye view as well as relevant details of the complex mechanisms at work. By focusing on stakeholders and their interests, this book analyzes the value propositions of the buyers and sellers of healthcare products and services along with the interests of patients.


The book begins with a presentation of frameworks for understanding the structure of the healthcare system and its dynamic stakeholder inter-relationships. The chapters that follow each begin with their social and historical origins, so the reader can fully appreciate how that area evolved. The next sections on each topic describe the current environment and opportunities for improvement.  


Throughout, the learning objectives focus on three areas: frameworks for understanding issues, essential factual knowledge, and resources to keep the reader keep up to date.


Healthcare is a rapidly evolving field, due to the regulatory and business environments as well as the advance of science. To keep the content current, online updates are provided at: www.HealthcareInsights.MD. This website also offers a weekday blog of important/interesting news and teaching notes/class discussion suggestions for instructors who use the book as a text.


The U.S. Health Care System: Origins, Organization and Opportunities is an ideal textbook for healthcare courses in MBA, MPH, MHA, and public policy/administration programs. In piloting the content, over the past several years the author has successfully used drafts of chapters in his Healthcare Systems course for MBA and MPH students at Northwestern University. The book is also useful for novice or seasoned suppliers, payers and providers who work across the healthcare field and want a wider or deeper understanding of the entire system.


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ABOUT THE AUTHOR


JOEL I. SHALOWITZ, MD, MBA, FACP, was Clinical Professor and Director of the Health Industry Management Program at the Kellogg School of Management for 28 years. In addition to practicing internal medicine, he has also been on Northwestern's Feinberg Medical School's faculty for more than 35 years, most recently as Professor of Preventive Medicine. He teaches and consults internationally, was the recipient of three Fulbright awards, and is currently a Senior Fellow at ETLA (the Research Institute of the Finnish Economy) and an Affiliate Professor at the Institute of Management of the Scuola Superiore Sant'Anna in Pisa.


作者簡介來源:

TABLE OF CONTENTS


List of Exhibits xiii


Foreword xxi


Acknowledgments xxiii


One: Understanding and Managing Complex Healthcare Systems 1


Definitions 2


Health System Structure and Features 7


Who Pays? 8


How Much Is Paid? 11


Who and What Is Covered? 12


Where Is Care Provided? 13


Who Provides the Services and Products? 14


Strategic Planning 17


Stakeholders 17


Health System Trade-offs and Value Propositions 20


Putting It All Together 30


Summary 32


Two: Determinants of Utilization of Healthcare Services 33


Reasons Stakeholders Seek Healthcare 34


Patient Characteristics That Influence Care-Seeking 36


Age 37


Gender/Sex 37


Race 39


Income 41


Social Status 42


Education 43


Culture and Beliefs 44


Multifactorial Causes 46


Reducing Patient Demand for Healthcare 47


Increase Out-of-Pocket Expenses 47


Prevention 51


Eliminate/Reduce Risky Behaviors 51


End-of-Life Issues 52


Healthy Lifestyle Promotion 54


Consumer Behavior—Healthcare Market Segmentation 54


Provider-Induced Demand for Healthcare 56


Local (Small Area) Variations 61


Summary 63


Three: Managerial Epidemiology 65


Introduction 66


What Is Epidemiology? 66


Why Is It Important to Learn about Epidemiology? 66


Definitions and Uses of Principles 67


Morbidity and Mortality 67


Incidence and Prevalence 67


Validity 67


Reliability 68


Sensitivity, Specificity, Positive Predictive Value, and Negative Predictive Value 68


Clinical Study Designs 70


Case Control Studies 70


Problems with Observational Research 72


Benefits to Employing Observational Research 73


Cohort Study 74


Randomized Controlled Trial 78


Summary 80


Four: Hospitals and Healthcare Systems 81


A Brief History of Western Hospitals 82


American Hospital Expansion in the 20th Century 88


Hospital Definition and Classifications 94


Definition 94


Ways Hospitals May Be Classified and Special Related Issues 96


Hospital Inpatient Payment Methods 137


Organized (Integrated) Delivery Systems/Accountable Care Organizations 139


Origins and Definition 139


Eligibility 143


Financial Arrangements 143


Hospital Governance 153


Definition and Purpose 153


Legal Requirements 154


Responsibilities 156


Board Structure and Activities 159


Summary 161


Five: Healthcare Professionals 163


Physicians 164


History of Western Medical Care 164


History of American Medical Care 177


Current Status of Medical Training 190


Licensure 197


Shortage of Physicians 199


Employment Status 204


Summary 206


Nurses 206


Registered Nurses 206


Nurse Practitioners 208


Nurse Anesthetists 209


Midwives 210


Education and Certification 212


Physician Assistants 213


Education and Certification 214


Physician versus NP/PA Care 215


Summary 216


Six: Payers 219


Principles of Health Insurance 220


The Loss Must Have Some Nontrivial Value Upon Which Both Insured and Insurer Agree 222


The Peril Must Occur Randomly and Be Out of the Control of the Insured 222


The Event Must Occur Neither Too Frequently Nor Too Rarely 225


The Insurer Must Be Able to Write Large Numbers of Contracts to Indemnify Similar Risks 226


Background and Current Status of Health Insurance in the United States 229


Private Health Insurance 229


Medicare 264


Medicaid 318


Children’s Health Insurance Program: Social Security Title XXI 335


Other Federally Sponsored Programs 337


Managed Care 357


Principles 361


Quality and Safety 361


Summary 381


Seven: Healthcare Technology 385


Definition and Frameworks for Study 386


Major Trends in Healthcare Technology 388


Safety 388


History of Safety Problems and Corrective Legislation 390


What Is Substantial Equivalence 404


When a 510(k) Is Required 404


Bringing Healthcare Technology to Market 435


Evolving Industry Structure 438


Globalization 444


Generics 444


Specialty Pharmaceuticals 446


Patents 453


Genomics and Precision Medicine 453


Disruptive Innovation 458


Healthcare Technology’s Contribution to Costs by Stage of Care 460


Overview 460


Quality-Adjusted Life Years 460


Core Cost Issues 462


Prevention 463


Screening 464


Diagnosis 464


Treatment 466


Other Considerations 470


Religious Issues 470


Ethical Issues 470


End-of-Life Costs 471


Media’s Role in Increasing Technology Costs 472


Malpractice and Defensive Medicine 473


Summary 474


Eight: Information Technology 475


Introduction 476


Definitions 477


Background and Key Issues in Health Information Technology 479


Collection, Classification, and Ordering of Data 479


Terminology/Coding 486


Interoperability 492


Lessons Learned 529


Challenges 529


Sustainability 529


Certification 534


Privacy and Security of Information 537


Management Considerations 547


Other Issues and Trends 549


Summary 563


Nine: Quality 565


Introduction 566


History of Healthcare Quality and Development of Key Concepts and Institutions 567


Ancient Origins 567


1900–1950 568


1950–1970s 574


1980s and Total Quality Management 580


1990s 589


2000–2010 592


2010–Present 605


Quality of Care and the Public’s Health 623


The Centers for Disease Control and Prevention 623


Healthy People 626


Definition of Quality 630


Key Questions for Successful Evaluation and Implementation of Quality Measures 632


Choosing Standards 633


Monitoring Standards 637


Evaluating Results 639


Volume/Quality Relationship 644


Managing Quality Improvement 646


Value Propositions 646


Cost–Quality Trade-off 648


Cost–Access Trade-off 648


Quality–Access Trade-off 649


Summary 649


Index 651 

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