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Healthcare Delivery in the U.S.A.
An Introduction
Margaret Schulte, DBA
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eBook - ePub
Healthcare Delivery in the U.S.A.
An Introduction
Margaret Schulte, DBA
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About This Book
With the same clarity that made the previous editions bestsellers, Healthcare Delivery in the U.S.A.: An Introduction, Third Edition provides readers with the understanding required to navigate the healthcare provider field. In the intervening 8 years since the 2nd Edition was published, there have been significant developments in the healthcare delivery systems, including COVID-19, global health issues, and the evolution of the Affordable Care Act and other financing mechanisms. Brilliantly simple, yet comprehensive, this updated edition includes updated case studies and describes the new organizational structures being driven by current market conditions. Focusing on healthcare management, the book addresses the range of topics critical to understanding the U.S. healthcare system, including the quality of care movement, delivering care during a pandemic, recent finance reform, new technologies, cyber security, and the recent increase in merger and acquisition activity. Dr. Schulte walks readers through the history of the development of U.S. healthcare delivery. She describes the various venues of care delivery as well as the different elements of the financing system. Offering a glimpse into the global market and medical tourism, the text includes coverage of legal and regulatory issues, workforce, and the drivers and barriers that are shaping healthcare delivery around the world. Painting a clear and up-to-date picture, this quick-and-easy read provides you with the understanding of the terminology, structures, roles, relationships, and nuances needed to interact effectively and efficiently with anyone in the healthcare provider field.
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Chapter 1History: U.S.A. Healthcare Delivery System
DOI: 10.4324/9781003202950-1
1.1 Introduction
In order to understand the fundamentals of how healthcare delivery works in the United States today, itâs valuable to take a brief look backward and review the history that has shaped healthcare delivery. Todayâs healthcare system is the outcome of the varied ideologies and philosophies, the evolving needs and wants, and the scientific and technological advances made in current and past generations. We live with the decisions our predecessors have made, and if we are to understand the healthcare system today, then it is important to be aware of what shaped our current healthcare system for better or for worse. Every part of it has evolved from the forces that shaped it in the past. For example, some question why employers in the United States today are so embedded in the financing of healthcare through employee health insurance. In other words, how did we get to the point at which employer-based health insurance has become such a burden on employers, for some of whom its costs exceed the profit they earn? The answer is important to an understanding of healthcare financing today. The short answer to the question is: during the boom in manufacturing to meet the needs of World War II and its immediate aftermath, federal mandates restricted employers from raising wages in light of looming rampant inflation. So, employers developed a new employment strategy to attract a much-needed workforce. Private health insurance had recently evolved and employers began offering health insurance as a benefit of employment. It was a competitive move that, ironically, 75 years later, has become an anti-competitive factor for those employers as they compete in international markets.
Historically, healthcare delivery traces its roots back to the fourth century B.C., to Hippocrates, who is often referred to as the âfather of medicine.â However, this book will not go back through the length of that rich past. We will instead fast forward to a more recent time frame and start nearer the historic time in which our country was founded.
1.2 1700 to 1850: The Early Days
In the early days of our country, there were no hospitals. People were reliant on itinerant physicians whose medical education was acquired through serving as apprentices to physicians. In most of the country, there were no hospitals. Doctors set up practices in their homes or small offices, and frequently made house calls to take care of their patients. When patients or their families could not afford to pay the doctor, bartering took place.
It was not until the mid-eighteenth century that the first U.S. hospitals were developed. Those first hospitals, unlike the hospital as we know it today, were developed to house the âinsaneâ and the poor. Some medical hospitals began to emerge later in a small wing of these institutions. In New York, Bellevue Hospital was among the first. It was established as a public hospital in 1736 with six beds placed in a section of the New York City Almshouse. In Philadelphia, on the other hand, Benjamin Franklin helped lead, along with his friend Dr. Thomas Bond whose idea it was, the founding of the private, non-profit Pennsylvania Hospital in order to care for the poor. (1) It was built in 1752, not as an almshouse, but as a place to deliver medical care. It offered some housing to the mentally ill with beds in the basement; where persons who were deemed insane could be removed from public life.
Hospitals made it possible for healthcare workers to work more efficiently and serve more people in rapidly growing cities because their patients could be gathered in one place rather than spread throughout the city in homes and tenements. Hospitals were designed primarily for the sick poor. Examples, in addition to Pennsylvania Hospital include institutions such as the New York Hospital which was built in New York City in 1771, and the Massachusetts Hospital built in Boston in 1791. (2) Wealthy individuals still insisted on seeing their doctors and receiving care in their homes in order to avoid exposure to infections and to retain their separation from the poor.
Medical and scientific discoveries and inventions accelerated the advancement of the medical profession. In two examples: Rene Laennec, a French doctor, invented the stethoscope in 1816, particularly for use in diagnosing chest infections, and James Blundell, a British obstetrician, performed the first blood transfusion in 1818. (3) Anesthesia was discovered in 1842 when Dr. Crawford Long first used ether as an anesthetic. He had noticed in his practice that individuals injured at social gatherings known as âether frolicsâ seemed to suffer no pain. Following his observation, in 1842 he administered ether to a patient and painlessly removed a tumor from his neck. (4) With anesthesia, patients were more willing to have a surgical procedure which meant that physicians could perform those procedures more readily and earlier in the case of disease or injury.
A third major development in the delivery of medical care in the middle of the nineteenth century was the initiative of physicians to organize for the advancement of medicine and medical education. In 1847, the American Medical Association (AMA) was founded. With the establishment of the AMA, a primary focus was brought to improve the medical education and training of doctors. (5) An important implication of these early days of âprofessionalizingâ medicine was the recognition of the need for structured and scientifically based medical education, for the sharing of medical knowledge, and for the documentation of the efficacy of new procedures.
1.3 1850 to the Late Nineteenth Century: Shift from Care to Cure
During the Civil War further significant advances provided the medical profession with the opportunity to reform care delivery. The emphasis of the medical community changed with the influx of the massive numbers of sick and injured soldiers and civilians who needed urgent surgical and other medical interventions. Anesthesia had just been discovered, and chloroform and ether came into widespread use in surgical suites.
The predominant health problems of the time related to infectious diseases. Deaths from infection were about twice as common as the predominant diseases of today (cardiovascular disease and cancer). In addition to anesthesia, the discovery in 1860 of bacteria as the source of infections and understanding the germ theory of disease helped to save the lives of many injured soldiers. This discovery laid the essential foundation for later advances in the control of infection. Advancements in the understanding of bacteria progressed quickly, and the first bacteriological and chemical laboratory was organized in 1889.
The Civil War provided, as wars always have, a âresearch laboratoryâ in which medical discoveries were made. Significant advances in the operational structures of care delivery were made during the war to achieve quality and efficiency improvements, all of which have evolved further over the 150+ years since the civil war, and are still central to care delivery as we know it today. Some of the contributions of the Civil War era to medical delivery include
- development of the medical record in which data were systematically gathered
- development of a system to manage mass casualties
- design of pavilion-style general hospitals, which were well ventilated and clean
- recognition of the importance of immediate, definitive treatment of wounds and fractures
- understanding of the importance of sanitation and hygiene in preventing infection and disease
- introduction of female nurses to hospital care
- upgrading the training of thousands of physicians and their introduction to new ideas and standards of care, such as prevention and treatment of infectious disease, anesthetic agents, and surgical standards.
(6)
Following the work of Florence Nightingale (1820â1910) and other nursing pioneers, nurses were finally recognized and admitted to work in hospitals. However, their education was not yet organized within a formal educational curriculum. So, along with the recognition of nursing as a profession, a general call for improvements in nursing education was made, and the first school of nursing opened in 1872 at the New England Hospital for Women and Children. This hospital had been founded in 1862 by women to be used exclusively for women and children with a women-only staff of physicians and nurses. (7) The establishment of additional schools of nursing throughout the country followed shortly after.
Scientific advancement in medicine continued during the latter half of the nineteenth century with the discovery of radiology by Wilhelm Roentgen in 1895. Initially called roentgenology, the field advanced rapidly and with the discovery of radioactivity a year later was re-named radiology.
By the latter part of the nineteenth century, the role of hospitals began to change again. With an understanding of bacteria and its role in illness, the discovery of anesthesia and other scientific advancements, and the importance of cleanliness in the control of infections, hospitals were able to advance quality improvement in their surgical procedures. They no longer needed to simply serve as âwarehousesâ for the sick, and they were thus able to reshape their mission and role in society. They transitioned from a focus on maintenance care for the sick to cure and healing of the sick and injured.
In addition to scientific discoveries and to the development and transition of hospitals, a third major development would advance medical care in the U.S. during the last half of the twentieth century. This related to the training of physicians. Physician training was woefully disorganized during the nineteenth century. Aspiring physicians were primarily educated by serving as apprentices. Those who could financially afford to do so went to major cities in Europe (e.g., Paris and London) to study and advance their medical education.
The only credible medical schools that existed in the U.S. were those at The University of Pennsylvania, Kingâs College (now Columbia College), and Harvard University, all founded in the latter half of the nineteenth century. As the country expanded and doctors were needed throughout the country, new medical schools were opened and proliferated. By 1876, 73 new medical schools were opened. They were privately owned, unsupervised, and lacked the structure needed for adequate medical training. There were no entrance requirements, and learning was completely didactic with all-day lectures supplemented with textbooks. The students had no opportunity to work with patients and there were no exams. Graduation was based effectively on the payment of fees. The medical education provided during those years was just a stumbling first step toward organized training. The early part of the next century would see significant progress in medical education.
1.4 1900 to the Mid-twentieth Century: Era of Standardization
At the start of the twentieth century and with the introduction of the âscientific methodâ in research, the pace of medical advances accelerated. In 1907, Ross Harrison, an American Zoologist and professor at Yale, discovered how to grow living cells outside the body. He found that nerve fibers grew from cultivated tadpole tissue, and his observations served as the foundation of todayâs study of nerve physiology and neurology. His achievement opened the door to the study of living organisms at the cellular level. (8) In 1919, cholesterol was found to influence coronary artery disease in humans, one of the major drivers of mortality in the twentieth and twenty-first centuries.
Sir Edward Banting led the team that discovered insulin in 1922, a discovery that had immediate impact globally for the masses of people who were diagnosed with diabetes. (9) Alexander Fleming, probably the best-known medical scientist of the era, discovered penicillin in 1928, a discovery that was to save thousands of lives during World War II after Pfizer perfected it for mass production.
Beyond medical discoveries, a small circle of medical leaders of the early twentieth century focused on the need for quality improvement in medical delivery, and, in order to accomplish this, they identified medical education as their first order of business. With the financial support of the Carnegie Foundation who had determined that improvement in medical education would be its philanthropic focus, they hired an educator, Abraham Flexner, who was known for his critical assessment of higher education in colleges in the U.S. and who had spent time studying medical education in Europe. He was commissioned by the Carnegie Foundation to perform an in-depth evaluation of medical schools in the country.
In 1910, the Flexner Report was released after four years of study under Flexnerâs leadership and after he visited all the medical schools in the country. He reported that (1) the quality of teaching in medical schools was poor, (2) there was an absence of hospital-based training in the medical schools, and (3) most medical graduates lacked adequate medical skills at graduation. The Flexner Report called on American medical schools to adopt higher admission standards, stronger graduation standards, the grounding of medical training in the basic sciences, and for medical students to receive hospital-based training along with their didactic classroom study. Many American medical schools fell short of ...