Challenges And Innovations In U.s. Health Care

Allen W. Imershein

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9780429724787
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

Increased concern in the 1960s about the quality and availability of health care in the United States prompted a variety of attempts to develop new policies and to modify the existing health care system. The authors of this book review some of those attempts and provide critical commentary on a broad range of new and continuing problems. Their succinct review of many vital aspects of the current health care system clearly demonstrates the successes and failures of health care policy and its impact on the overall system. The authors discuss consumer involvement in the health care system, the development of neighborhood health clinics, health maintenance organizations and health systems agencies, veterans' medical care, chiropractic, the use of non-physicians in care, changing ideologies among physicians, and the impact of health education. A variety of analytical perspectives are used to evaluate the many issues raised, ranging from a highly critical Marxist commentary on fundamental flaws in the U.S. health system to a pluralist analysis of how the current system might be made to work better.

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American Health Care: Paradigm Structures and the Parameters of Change

Allen W. Imershein Florida State University

Recent commentary on the health care scene in the United States has moved increasingly toward explanations of why little or no change has occurred, despite many declarations of crisis." From Alford's (1975) elitist analysis in Health Care Politics to Navarro's (1976) Marxist analysis in Medicine Under Capitalism, critics in and out of the social sciences have tried to make sense of the array of current problems and the apparent lack of response to them. These analyses are in striking contrast to earlier commentaries (e.g., Schwartz, 1971; Garfield, 1970; Anderson, 1972; Citizens Board, 1972) that, although highly critical of then current health care arrangements, foresaw the potential for change within the system and often made recommendations for potential solutions. These earlier analyses might have been characterized by an unwarranted optimism regarding the potential for change, but recent analyses have more than counter-balanced that orientation with an overwhelming skepticism regarding the likelihood of any significant change, short of a major societal restructuring. From the elitist perspective, Alford sees our health care system as rooted in the distribution of power and control in the United States; from a Marxist perspective, Navarro sees the fundamental economic structure of the society as the basis for the current health care system. Thus both believe that no significant change should have been, nor can be, expected.

Despite such criticisms, there have been increasing attempts made in the public arena to change the delivery of health care. Government involvement in financing (actual and proposed), the development of health maintenance organizations (again often under government sponsorship), the establishment of health systems agencies as regulatory organizations, the training of physician extenders and other new allied paraprofessionals, the emergence of family practice as a specialty, and the renewed interest in health education are all examples of the immense energy apparently directed toward answering perceived health care needs. For a field in which current critics tell us there is little potential for significant change, there appears to be a lot going on.

The chapters¹ in this book report some of those "goings on." What is particularly notable about them is that the analytical perspectives and value commitments of the authors are as widely varied as the studies themselves, and probably reflect the range of perspectives in the larger health care arena. Some of the studies have no particular theoretical commitments, while at least two (Lasker and MacDougall) identify themselves in some fashion with a Marxist perspective, and one (Bodenheimer and Dixon) is avowedly Marxist. Also, some of the analyses are based on the framework of "established" assumptions currently espoused by major segments of the health care system, even when the analyses criticize implementation within that framework; others challenge even the most basic assumptions. The conclusions drawn from such different approaches are, needless to say, vastly different. The contents of this volume reflect both the range of issues and the range of approaches that characterize the ongoing changes and conflicts in the health care arena. We have not attempted to provide any definitive answers on the significance of current changes or on definitive methods for examining the questions, which may or may not actually be answerable. Rather, we have tried to provide some examples of how different people have gone about accomplishing that task.

In this introductory chapter, I will briefly review the major points and perspectives addressed in the following chapters, and then try to provide a general framework one might use for addressing the questions of change and significance.

Recent Studies of Innovation and Change

The first several chapters focus on specific attempts at change or innovation. Most of these attempts were made in response to a range of perceived problems in the health care system. The litany is a familiar one: maldistribution of physicians both geographically and across specialities, inaccessibility of care, excess cost to consumers, lack of prevention, spiralling costs, lack of coordination and integration of services (see, for example, Heal Yourself, 1973; or Ehrenreich and Ehrenreich, 1970). Together these elements constitute the major characteristics cited as evidence of a health care crisis, and they have provided either the instigation or the legitimation for a great variety of reform attempts.

In Chapter 2, Bebe Lavin looks at the need for and potential of non-physician primary care assistance. The lack of available physicians, especially for primary care; the possibility of using physicians' time more efficiently by allocating non-essential tasks to less highly trained personnel; and the desire to include less technical, more wholistic elements in the care process, have all contributed to growing pressure for non-physician professionals. Given that primary-care visits are estimated to constitute 60 percent of all physician visits and that some estimate that 60 to 80 percent of requests at these visits could be handled by someone other than a physicians, the potential for the use of less highly trained personnel, such as physician assistants or family nurse practitioners, seems great indeed. However, Lavin finds significant tension underlying such practices and limiting their potential: the question of public acceptance. Those who are most educated and most knowledgable about their own health (the middle and upper classes) are more willing to accept non-physician care; but given the existing problems of physician distribution, they are also the least likely to receive such alternative care. Instead, rural dwellers and the urban poor, who are on the whole less educated and less willing to forego the authority and expertise attributed to a physician, are most likely to be exposed to non-physician care because of the local scarcity of physicians. Lavin examines the problems encountered here and considers the conditions that would make public acceptance more likely.

Health maintenance organizations (HMO's) have been in existence for many years, but only recently has the federal government become involved in encouraging their development. HMOs are seen as a method of organizing care in order to reduce costs, increase consumer accountability, and improve the quality of care, especially by emphasizing preventive rather than crisis care. In Chapter 3, Judith Barr and Marcia Steinberg examine the implementation of HMOs with particular emphasis on the impact it has had on physician autonomy. Autonomy is a central issue because it is defined (following Freidson, 1970) as the core characteristic essential to the physician's role as an independent professional. When a new organizational program involving bureaucratization and government intervention is seen as challenging traditional physician roles and authority, the implications of that program approach are taken very seriously by the medical profession (of. the long history of AMA opposition to HMO type structures). Barr and Steinberg argue that, in fact, little threat is posed to physician autonomy by HMOs because physicians for the most part are able to control both the process and the results of HMO implementation. Professional norms may be challenged, but their authority appears to be maintained.

In Chapter 4, Bonnie Edington examines the confusion generated by a legislative mandate that demanded the conflicting goals of achieving containment, quality improvement, and greater accessibility at the same time. Planning and coordination emerged as a high priority in the 1960s, and as a result the Comprehensive Health Planning Agencies came into being. These agencies were replaced in the mid-1970s by Health Systems Agencies (HSAs) under the National Health Planning Act of 1974. HSAs were supposedly designed to plan and coordinate health services in designated areas throughout the country. But here as elsewhere contradictions abound, and sometimes prevail. Attempts to improve service while also reducing costs have often resulted in simple stagnation. A major upshot of the inability to do both has been a tendency to blame the victim for "overusing" health care services (thus raising costs), for eating improperly and following "unhealthy" lifestyles, and so on. Edington provides an overview of the development of the HSAs, analyzes the contradictions, and considers the results of the process.

One of the more widely hailed health care innovations of the 1960s was the development of neighborhood health centers (NHCs). As part of the "Great Society" program, NHCs were seen as a means to make low-cost health care more available to low income groups, particularly in badly underserved and explosive inner-city neighborhoods. They were to be organized in a fashion that would be responsive to neighborhood needs, that would encourage citizen participation, and that would provide local employment. To say that Tom Bodenheimer and Marlene Dixon came to negative conclusions about the reality of these NHCs is to state the case mildly. The authors of the first three chapters have taken no explicit theoretical position, but Bedenheimer ad Dixon provide a clearly Marxist critique that is both vehement and biting. Using case analysis, they argue that NHCs have failed to be responsive and to provide needed care, and worse, they have served as vehicles for government exploitation of the poor and as tools for domestic counterinsurgency. In their opinion, since the health care system is presently controlled by dominant political and economic interests, we should not have expected otherwise.

In Chapter 6, Judith Lasker tackles the veterans Administration. Just as the National HMO Act was built upon earlier models of HMO activity, so other systems and organizations serve as models for potential national health care financing or health care services. The Veterans Administration is our main existing government financed, federally run system within the free "enterprise" health environment. Lasker examines the dynamics of VA functioning and evaluates its potential as a model for a national health service. Those who favor a national health service have often cited the VA as an example of successful government financing and management in the health care field, but Lasker sees problems in using the VA as a model. The VA has been subject to the influence, if not the control, of dominant political, economic, military, and medical interests and therefore has not necessarily been organized to best serve the interests and needs of the veterans for whom it supposedly exists. Lasker suggests that a national service modeled in similar fashion would suffer from similar conflicts in management and wind up failing to serve the public it was intended for.

With a growing elderly population we have become increasingly concerned about care for the elderly and for dying patients. Patient-physician communication and interaction have also become central concerns to many of us. In Chapter 7, John MacDougall examines changes in physician ideologies regarding interaction and communication with dying patients as a means to explain, and as an indicator of, general changes in patterns of physician behavior. In particular, MacDougall finds evidence that current physician ideologies favor more openness toward dying patients and greater coordination with professional teams, reflecting structural changes in the organization of care. Physicians are now less independent, and must rely on technological equipment and bureaucratic settings that are in turn dependent upon corporate and government funding. Changing physician ideologies can thus be linked to underlying challenges to the traditional character of medical practice and are indicative of the corporatization of medicine.

If medicine has been challenged from within, it has also been challenged from without. In a follow-up of his now classic article, Walter Wardwell examines the development and status of one of medicine's principal outside challengers: chiropractic. While at one time it was relegated to the status of a marginal health profession, as Wardwell earlier had characterized it, chiropractic has evolved to the status of a chief rival of orthodox medicine. Evidence of this success lies in the accreditation of its colleges, its being granted reimbursement status under medicare, and the achievement of licensing authority in all states. Both the challenging, confrontive tactics of chiropractic and its overt and vocal rejection by orthodox medicine have subsided. The more general acceptance and use of chiropractic may indicate either a movement of chiropractic toward orthodox medicine (for which there is little evidence) or a willingness of the public to seek beyond orthodox medicine (which is more likely the case). As Wardwell notes, the triumph of chiropractic provides fascinating commentary on the status of orthodox medicine.

In Chapter 9, Ann Ford and Scott Ford take a look at who's practicing what they preach when it comes to healthy life-styles. Potentially preventable (and not easily curable) diseases are now the major causes of morbidity and mortality in this country, and we are also concerned with alleged over-use of health care facilities and the need to reduce or at least contain the costs of health care. Therefore there has been growing interest in disease prevention, healthy life-styles, and health education. While the general public may acknowledge these concerns, Ford and Ford found that healthy lifestyle practices may be observed more in the telling than in the doing. Those who know what healthful practices are do not always engage in them. Moreover, a consistent correlation of high levels of tension with unhealthy lifestyle habits (e.g., smoking and snacking), and an inverse relation between tension and healthful practices (e.g., exercise and seat belt use) suggests that there may be external factors that determine whether an individual will choose a healthy life-style. Health education may be proposed as a useful tool for improving our national health, but modification of other, more systemic factors may be necessary before any significant change can occur.

In Chapter 10, A1 Imershein and Gina Miller consider two aspects of the movement for increased consumer involvement in health care that appear to be potentiallychallenging to current arrangements. Imershein and Miller examine the participation of consumers in the organization of health care and look at the self-care movement. The addition of health care consumers to decision-making todies was initially hailed as a breakthrough that would increase the responsiveness of health care organizations to consumer needs, but the ineffectiveness of such bodies or their continued dominance by health care providers has blocked any real change. However, the self-care movement, which focuses on practices essentially independent of traditional health care, may have long-term viability and potential for change, if it does not evoke active opposition or provoke attempts at cooptation by the medical establishment.

Obviously the range of issues considered in this volume is only representative of the full range of issues in health care today. But the character of those changes and the major perspectives on the issues are well represented by this collection of papers. I would now like to look at how some of these issues relate to the positive and negative general critiques of the overall health care arena I noted at the outset.

Paradigm Structures in American Health Care

Elsewhere (imershein, 1977a, 1977b) I have argued the utility of conceptualizing American health care as an organizational paradigm, following Kuhn's (1970) analysis of scientific paradigms. That framework is useful here, I believe, for examining both the limited potential for significant change and the actual appearance of a wide array of more limited changes. First, American medical practice can best be understood as a paradigm community, with physicians, medical educators, and hospital administrators as the primary community members and with the general public acting in response to this community. Second, as a paradigm community, the medical establishment's major activities are ordered by virtue of widely shared, taken-for-granted models of practice. Third, these dominant models are in turn intrinsically linked to certain assumptions about the nature of health, illness, and medicine and about how physicians and health care (or more narrowly, medical care) should be related to the larger society. Finally, given the dominance of this paradigm community within the larger society, these practices and assumptions are established as well by custom, by rule of law, by influence over the ongoing political process, and by some control of economic resources relevant to the area of practice.

Change in this paradigm community can occur in two different ways. First, there are the changes that occur as the result of the "natural" development of the paradigm; for example, the extension of existing patterns of practice to relatively new areas or the development of new modes of practice based upon and consistent with existing arrangements (see Kuhn, 1970: Ch. 3, for a discussion of scientific paradigm development). Second, major changes - those fundamentally altering existing practices - only occur through revolution; that is, through rejection of the dominant paradigm and accepta...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• List of Tables
• 1 AMERICAN HEALTH CARE: PARADIGM STRUCTURES AND THE PARAMETERS OF CHANGE
• 2 THE PUBLIC AND CARE BY NON-PHYSICIANS: HEALTH POLICY CONSIDERATION
• 3 ORGANIZATIONAL STRUCTURE AND PROFESSIONAL NORMS IN AN ALTERNATIVE HEALTH CARE SETTING: PHYSICIANS IN HEALTH MAINTENANCE ORGANIZATIONS
• 4 THE PARADOXES OF HEALTH PLANNING
• 5 MISSION NEIGHBORHOOD HEALTH CENTER: A CASE STUDY OF THE DEPARTMENT OF HEALTH, EDUCATION AND WELFARE AS A COUNTERINSURGENCY AGENCY
• 6 VETERANS’ MEDICAL CARE: THE POLITICS OF AN AMERICAN GOVERNMENT HEALTH SERVICE
• 7 CHANGING PHYSICIAN IDEOLOGIES ON THE CARE OF THE DYING: THEMES AND POSSIBLE EXPLANATIONS
• 8 THE TRIUMPH OF CHIROPRACTIC -- AND THEN WHAT?
• 9 THE GOOD LIFE: WHO’S PRACTICING HEALTHY LIFE-STYLES?
• 10 THE IMPACT OF CONSUMERISM ON HEALTH CARE CHANGE: ALTERNATIVES FOR THE FUTURE?