The US Healthcare System

The Meat of the U.S. Health Care System: Doctors, Nurses and

Hospitals

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

Types of Healthcare Worker Certification

Licensure – state or legal designationCertification and registrationIndependent and dependent professions

Independents practice without physician supervision (e.g., doctors, dentists)

Dependents need physician supervision (most nurses, CNAs)

Physicians

Comprised of two types by practicePrimary care physicians – short supply in

U.S.Family Practice, Internal medicine, OB/GYN,

PediatriciansSpecialists – Surplus in U.S.

Specialize in specific areas

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

Changing Role of the Physician

More employed physiciansBy 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

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 specialties414/100 521/100 630/100 684/100 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

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

The Evolution of the Physician in the U.S.

AllopathicHomeopathyOsteopathicChiropractic

Physicians

Comprised of two types by practicePrimary care physicians – short supply in

U.S.Family Practice, Internal medicine, OB/GYN,

PediatriciansSpecialists – Surplus in U.S.

Specialize in specific areas

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

Physicians: NV vs. US

Physicians Type Nevada U.S.

Generalists/100,000 pop. 21 30

Specialists/100,000 pop. 142 206

Changing Role of the Physician

More employed physiciansBy 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

Physicians who would recommend the practice of medicine

48%

41%

11%

Yes

No

Don't know

46%

31%

20.0%

31%

22%

16%

15%

1%

8%

0% 10% 20% 30% 40% 50%

Loss of autonomy

Excessive professional demands

Less respect for the medical profession

Inadequate financial rewards

Difficulty operating practice

Education process to long/expensive

Not Satisying

Liability

Other

For physicians who wouldn’t recommend medical profession

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 specialties414/100 521/100 630/100 684/100 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

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

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

0

20

40

60

80

100

120

140

160

180

Primary CareVisit

SurgicalSpecialty

MedicalSpecialtyPractice

OutpatientDept.

EmergencyDept.

1993-94

1999-2000

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

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

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?

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

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)

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

Number of Public Community Hospitals, U.S.

0

200

400

600

800

1,000

1,200

1,400

1,600

1991 1992 1993 1994 1995 1996 1997 1998 1999 200 2001 2002

Constraining and Propelling Forces Affecting Hospital

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

Hospital Beds per 1,000 population by Ownership, 2002

Nevada U.S.

State/Local Government Hospital Beds

17% 16%

Non-Profit Hospital Beds

32% 71%

For Profit Hospital Beds

51% 13%

Background: Las Vegas Hospitals September, 2001

Total Govt. (n=2)

Private, For-Profit

(n=6)

Private, Non-Profit

(n=3)

Number of Hospital Beds

2972 639 1963 370

Number of ER Beds 272 61 161 50

Isolation Beds 166 46 58 62

ER Clinicians 379 95 240 44

Security Staff 136 49 67 20

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

0

10

20

30

40

50

60

70

80

90

1970 1976 1980 1986 1990 1994 1998

State and county

Private Psychiatric

Non-federal general

VA Med Centers

RTCs

All Others

Who Gets Treatment for Mental Illness?

8%7%20%

65%

Mental or Addictive illnessreceiving treatment

No defined illness,received treatment

Mental or addictiveillness, not treatment

No defined illness, notreatment

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

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

0

20

40

60

80

100

120

140

160

180

Primary CareVisit

SurgicalSpecialty

MedicalSpecialtyPractice

OutpatientDept.

EmergencyDept.

1993-94

1999-2000