The US Healthcare System

1. The US Healthcare System The Meat of the U.S. Health Care System: Doctors, Nurses and Hospitals

2. Healthcare Professionals • Healthcare is a major employer • It has a rapidly growing labor sector • Professionals • Non-professionals and technicians • Non-institutional workers • Rapid growth due to: • Technology growth and specialization • Health insurance coverage • Aging population • Emergence of hospitals

3. Types of Healthcare Worker Certification • Licensure – state or legal designation • Certification and registration • Independent and dependent professions • Independents practice without physician supervision (e.g., doctors, dentists) • Dependents need physician supervision (most nurses, CNAs)

4. Physicians • Comprised of two types by practice • Primary care physicians – short supply in U.S. • Family Practice, Internal medicine, OB/GYN, Pediatricians • Specialists – Surplus in U.S. • Specialize in specific areas

5. Physician Surplus or Shortage? • Rapid growth of physicians, esp. specialists, during 1980-95 due to: • Massive federal outlays • Influx of International Medical Graduates (IMGs) • Maldistribution of physicians can give appearance of shortage • Not enough primary care providers • Medical underserved areas in rural communities and inner cities • Malpractice and the impact on physicians

6. Changing Role of the Physician • More employed physicians • By managed care organizations and hospitals (the emergence of the “Hospitalist”) • Large group practices emerged with the growth of managed care • Emphasis away from specialty areas to managed care • More female physicians

7. Distribution of Physicians by Specialty: 1980, 1986, 1995, 2000 (In thousands 1980 1986 1995 2000 Pct. Change Specialty No./% No./% No./% No./% 1986-2000 All specialties 414/100 521/100 630/100 684/100 31.4 Primary Care 159/38.5 179/34.4 205/32.5 219/32.0 22.2 Other Medical Specialties 25/6.2 62/12.0 83/13.2 94/13.7 50.2 Surgical Specialties 110/26.7 134/25.7 158/25.2 170/24.9 27.0 All other specialties 118/28.5 144/27.8 183/29.1 201/29.4 38.9

8. Physician Authority • Based on modern science and scientific knowledge. • Physicians become the intermediaries between science and private experience • Authority signifies the presence of status and quality • Requires legitimacy and dependence. • Legitimacy – acceptance by subordinates • Dependence – bad things can happen if we don’t obey • Types of Physician Authority • Social Authority • Cultural Authority • Professional Authority

9. The Evolution of the Physician in the U.S. • Allopathic • Homeopathy • Osteopathic • Chiropractic

10. Physicians • Comprised of two types by practice • Primary care physicians – short supply in U.S. • Family Practice, Internal medicine, OB/GYN, Pediatricians • Specialists – Surplus in U.S. • Specialize in specific areas

11. Physician Surplus or Shortage? • Rapid growth of physicians, esp. specialists, during 1980-95 due to: • Massive federal outlays • Influx of International Medical Graduates (IMGs) • Distribution of physicians gives appearance of shortage • Not enough primary care providers • Medical underserved areas in rural communities and inner cities • Malpractice and the impact on physicians

12. Physicians: NV vs. US

13. Changing Role of the Physician • More employed physicians • By managed care organizations and hospitals (the emergence of the “Hospitalist”) • Large group practices emerged with the growth of managed care • Emphasis away from specialty areas to managed care • More female physicians

14. Physicians who would recommend the practice of medicine

15. For physicians who wouldn’t recommend medical profession

16. Distribution of Physicians by Specialty: 1980, 1986, 1995, 2000 (In thousands 1980 1986 1995 2000 Pct. Change Specialty No./% No./% No./% No./% 1986-2000 All specialties 414/100 521/100 630/100 684/100 31.4 Primary Care 159/38.5 179/34.4 205/32.5 219/32.0 22.2 Other Medical Specialties 25/6.2 62/12.0 83/13.2 94/13.7 50.2 Surgical Specialties 110/26.7 134/25.7 158/25.2 170/24.9 27.0 All other specialties 118/28.5 144/27.8 183/29.1 201/29.4 38.9

17. Physician Medical Education • Undergraduate medical curriculum • Most emphasize the acute care setting • Increase in women and minorities • Graduate medical education • Major increases in residencies • Shifts in the organization of medical schools • Must compete for patients • Shift to managed care by med school hospitals • Trends medical education in for-profit hospitals • Flexnor Report

18. Patient Visits per 100 persons by Ambulatory Service Type, 1993-94 and 1999-2000

19. Nurses • Typifies the concern of healthcare: “nursing is concerned with human response to health problems” • Historic factors that shaped nursing as a career: • Occupation to support physicians • Emergence of hospitals as community institutions • Acceptable female occupations, primarily white females • Linked to religious orders

20. Understanding the Nursing Shortage • Changes in occupational opportunities for women since 1970s • Majority of RNs are 50+ years of age or married with children at home • Low salaries – pay compression • Burnout • Lack of clinical career ladder • Active vs. Inactive – about 1/3 of nurses not working fulltime

21. The Nursing Shortage Snapshot • Estimated shortfall of 1.1 million RNs in U.S. by 2012 • Demand requires at least 110,000 more nursing graduates/year. • Shortage of nurse faculty: enrollment up by 13% in 2005, but more than 36,000 qualified applicants turned away. • Some Solutions? • Improve work environment conducive to recruiting new nursing faculty and retaining nurse educators • Increase amount of public and private funding for nursing programs • Implement new methods of instruction. • Improve partnerships between nursing schools and clinical sites • Is importing nurses a solution?

22. Hospitals • The growth of Hospitals in the U.S. is a fairly recent history: • Hill-Burton • Hospital Insurance • Advances in medical science • Professional nursing • Improved medical school training for physicians • Cost containment practices have lowered hospital utilization • Decreased inpatient utilization through DRGs and managed care • Shift to outpatient services • System and specialty hospital growth

23. Hospital Classification • For-profits – fastest growing type of hospitals • For-profit and non-profit systems (e.g., Kaiser Permanente, Catholic Hospitals West) • Public Hospitals • Numbers are in decline • Serve disproportionate number of Medicaid and uninsured • Account for nearly 25% of uncompensated care • Includes federally funded facilities such as VA and Armed Services facilities (McCallahan Federal Hospital)

24. Hospitals (types cont.) • Academic teaching hospitals • Tripartite mission • Face shaky future • Rural Hospitals • Small, non-profit • Many with nursing home swing beds • Endangered • Quality of care in question • Types of services available being lost to cities

25. Number of Public Community Hospitals, U.S.

26. Constraining Governmental and third party purchaser pressure for cost containment Competition from multi-hospital systems and local physicians Conservatism of some traditionally oriented practicing physicians Cost of continuing technological advances Slower growth of the economy Changing governmental philosophy toward health care Propelling New health markets other than inpatient care Weakening power of physicians in the hospital New organizational structures Increasing power of a more business-oriented management team Aging of the population Changing customer expectations for service Constraining and Propelling Forces Affecting Hospital

27. Hospital Beds per 1,000 population by Ownership, 2002

28. Background: Las Vegas Hospitals September, 2001

29. Percent Distribution of Mental Health 24-hour hospital and residential treatment beds

30. Who Gets Treatment for Mental Illness?

31. Ambulatory Care • Personal health care given to the patient in an non-hospital or institutional setting • Types of settings: • Physician owned private practice • Managed care clinic settings • Community health care settings • “Urgent care” facilities • Shift to ambulatory care due to several factors: • Medicare PPS • Managed care • Improved technology

32. Patient Visits per 100 persons by Ambulatory Service Type, 1993-94 and 1999-2000