The U.S. Healthcare System

Origins, Organization and Opportunities

Joel I. Shalowitz

• Publisher: Jossey-Bass
• Year: 2019
• Print ISBN: 9780470631522
• eBook ISBN: 9781118415399
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

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: 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.

CHAPTER 1
UNDERSTANDING AND MANAGING COMPLEX HEALTHCARE SYSTEMS

DEFINITIONS

JULIET.

…What's in a name? That which we call a rose

By any other word would smell as sweet…

—William Shakespeare, Romeo and Juliet, Act 2, Scene 2

Anyone who can set the terms of a debate can win it.

—Attributed to George Edward Reedy, White House press secretary under U.S. President Lyndon B. Johnson

Before we try to understand how healthcare systems are structured and function, we need to consider some definitions. First, how do we define the word “health”? The answer is important because it frames such decisions as our population focus for care, how we design facilities, how we train our professionals and ancillary personnel, how we develop new technologies, and how we structure insurance products. Unfortunately, many societies (including the United States) define health in terms of the absence of disease and focus on acute care as their model of what society should provide.¹ This view about the meaning of health is strikingly obvious if one compares self-reported health status to objective measures, such as life expectancy. For example, in a survey of 37 countries, Japan's ranking for self-reported health is 36th and the United States is first. However, Japan's life expectancy ranks first while the United States ranks 27th.²

Since health is often viewed as an absence of some type of bodily derangement, we first need to define three terms: illness, disease, and sickness. Dictionaries often provide circular definitions for these three terms, but it is useful to distinguish among them for purposes of addressing the healthcare issues just mentioned. The most helpful explanations were written by Marinker³ more than 40 years ago:

[Disease is] a pathological process, most often physical as in throat infection, or cancer of the bronchus, sometimes undetermined in origin, as in schizophrenia. The quality which identifies disease is some deviation from a biological norm. There is an objectivity about disease which doctors are able to see, touch, measure, smell.

[Illness is] a feeling, an experience of unhealth which is entirely personal, interior to the person of the patient. Often it accompanies disease, but the disease may be undeclared, as in the early stages of cancer or tuberculosis or diabetes. Sometimes illness exists where no disease can be found. Traditional medical education has made the deafening silence of illness-in-the-absence-of-disease unbearable to the clinician. The patient can offer the doctor nothing to satisfy his senses—he can only bring messages of pain to the doctor…The traditional remedy for this distress (I am of course talking about the distress of the doctor and not the distress of the patient) is to translate the illness language of diseases that do not require objects available to the doctor's eyes, ears or hands. I am talking about psychiatric language.

[Sickness is] the external and public mode of unhealth. Sickness is a social role, a status, a negotiated position in the world, a bargain struck between the person henceforward called “sick,” and a society which is prepared to recognize and sustain him. The security of this role depends on a number of factors, not least the possession of that much treasured gift, the disease. Sickness based on illness alone is a most uncertain status. But even the possession of disease does not guarantee equity in sickness. Those with a chronic disease are much less secure than those with an acute one; those with a psychiatric disease than those with a surgical one. The diseases of the old are less highly regarded than those of the young; I do not dare to suggest that diseases of women are inferior to those of men. Best is an acute physical disease in a young man quickly determined by recovery or death—either will do, both are equally regarded.

Given these definitions of disorders, we can now consider the definition of “health.” According to the World Health Organization (WHO): “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”⁴ It is obvious that a policy focus on this definition will yield different priorities than a policy that relies on the ones above.

These definitions invite the question: What are the priorities of the U.S. healthcare system? In other words, what is its mission? After reading the examples in Exhibit 1.1, it should be obvious that one of the principle problems is that the United States does not have a mission statement that guides health policy.

EXHIBIT 1.1. Examples of Mission Features for Healthcare Systems

1. Universal Declaration of Human Rights. Adopted and proclaimed by U.N. General Assembly Resolution 217 A (III) of December 10, 1948 Article 25. (1): Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
2. National Health Service. When former British Prime Minister Gordon Brown was Chancellor of the Exchequer, he said that taxation to fund healthcare is fair compared to:
   • User Charges. “[I]t does not charge people for the misfortune of being sick.”
   • Private Insurance. It “does not impose higher costs on those who are predisposed to illness, or who fall sick.”
   • Social Insurance. “[I]t does not demand that employers bear the majority burden of health costs.”^a
3. Policy and administrative objectives for Canadian healthcare.
   • Public Administration. The provincial and territorial plans must be administered and operated on a nonprofit basis by a public authority accountable to the provincial or territorial government.
   • Comprehensiveness. The provincial and territorial plans must insure all medically necessary services provided by hospitals, medical practitioners and dentists working within a hospital setting.
   • Universality. The provincial and territorial plans must entitle all insured persons to health insurance coverage on uniform terms and conditions.
   • Accessibility. The provincial and territorial plans must provide all insured persons reasonable access to medically necessary hospital and physician services without financial or other barriers.
   • Portability. The provincial and territorial plans must cover all insured persons when they move to another province or territory within Canada and when they travel abroad. The provinces and territories have some limits on coverage for services provided outside Canada, and may require prior approval for non-emergency services delivered outside their jurisdiction.
   • Also: Efficiency, Value for Money, Accountability, and Transparency^b
4. Principles of the Servizio Sanitario Nazionale (Italian National Health Service)
   • Human Dignity. Every individual has to be treated with equal dignity and have equal rights regardless of personal characteristics and role in society.
   • Protection. The individual health has to be protected with appropriate preventive measures and interventions.
   • Need. Everyone h...

Table of contents

• COVER
• TABLE OF CONTENTS
• LIST OF EXHIBITS
• FOREWORD
• ACKNOWLEDGMENTS
• CHAPTER 1: UNDERSTANDING AND MANAGING COMPLEX HEALTHCARE SYSTEMS
• CHAPTER 2: DETERMINANTS OF UTILIZATION OF HEALTHCARE SERVICES
• CHAPTER 3: MANAGERIAL EPIDEMIOLOGY
• CHAPTER 4: HOSPITALS AND HEALTHCARE SYSTEMS
• CHAPTER 5: HEALTHCARE PROFESSIONALS
• CHAPTER 6: PAYERS
• CHAPTER 7: HEALTHCARE TECHNOLOGY
• CHAPTER 8: INFORMATION TECHNOLOGY
• CHAPTER 9: QUALITY
• INDEX
• END USER LICENSE AGREEMENT