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by: Sharon Stambouli


Sharon Stambouli
GPA 3.95

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Here are all the summarized notes from the textbook’s chapter 3
Statistics for Biology Majors
Dr. Chanadra Whiting
Class Notes
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This 9 page Class Notes was uploaded by Sharon Stambouli on Thursday September 8, 2016. The Class Notes belongs to HSA 3111 at Florida International University taught by Dr. Chanadra Whiting in Fall 2016. Since its upload, it has received 6 views. For similar materials see Statistics for Biology Majors in Statistics at Florida International University.

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Date Created: 09/08/16
HSA 3111 CHAPTER 3 STUDY GUIDE Evolution of Health Services in the United States The U.S. Health Care Delivery System The US health care system is shaped by anthrocultural values and the social, political, and economic antecedents. ü A national health care program has failed to make inroads § Although compromises have been made (e.g., Medicare, Medicaid) ü The ACA was passed without broad consensus from Americans Medical science and technology have played a major role in shaping US health care by: ü Influencing medical education ü Making it possible to deliver medical services in settings other than hospitals ü Promoting corporatization of medicine, both nationally and globally Four Main Eras in US Health Care Evolution ü Pre-industrial – consumer sovereignty • Medical practice in disarray • A trade, not a profession • Primitive medical procedures • Bleeding, emetics, purgatives • Missing institutional core • Almshouses and pesthouses • Dispensaries • Mental asylums • Unstable demand • Self reliance • Substandard medical education • Apprenticeship • College-based education lacked scientific training ü Post-industrial – professional dominance • American physicians gained professional sovereignty and resisted national health care • Transformation due to: • Urbanization • Science and technology • Institutionalization • Patient Dependency • Autonomy and Organization • Licensing • Educational Reform • Urbanization • People distanced from families • Women entered the workforce • Reduced opportunity cost for physician services • Increased physicians’ productivity • Science and Technology • Cultural authority • General acceptance of and reliance on the judgment of members of a profession • Increased demand for professional services • Decreased reliance on familial treatments • Institutionalization • Medical technology, professionalization, and urbanization necessitated the pooling of resources • The hospital became the institutional core of health care delivery • Dependency created by: • Society’s expectation that the sick obtain medical care to get well • The profession’s cultural authority • Autonomy and Organization • Independence of physicians from hospital and corporate control—corporate practice doctrine • Organized medicine • Concerted activities of physicians through the AMA • Licensure • Medical Practice Acts of the 1870s • Dent v West Virginia (1888) • Necessitated upgrading of medical education • Relieved the intense competition in medical practice • Educational Reform • Harvard and Johns Hopkins reformed medical education • Laboratory instruction and science were added to the curriculum • Medical education became a graduate training course • Proprietary schools closed as they could not comply • The AMA’s control over medical education [Council on Medical Education] • The Flexner Report – 1910 • Corporatization – corporate dominance • Health care reform – government dominance Community Mental Health ü National Mental Health Act of 1946 § Funding for education and research ü NIMH § Early treatment of mental disorders ü Community Mental Health Centers Act of 1963 § Reduction in state-run psychiatric beds ü Olmstead v. L. C. § Deinstitutionalization Specialization in Medicine ü A hallmark in American Medicine § 58:42 - specialist to generalist ratio § Specialized fields in allied health professions ü Unlike Britain, the structure of medicine in the US did not develop around a nucleus of primary care, but § The gatekeeping model can be seen in HMOs—initial contact with general practitioner required for a referral to a specialist Development of Public Health ü Public health in the US developed in response to deadly outbreaks of communicable diseases ü Separate from private practice of medicine § Due to physician’s skepticism of controlling private medical practice § Private practice’s focus on the individual (not community) Health Services for Veterans ü After World War I ü Moved from mainly private contracting to facilities owned by the Department of Veterans Affairs Workers’ Compensation ü 1914 § Work-related injuries and illnesses are the responsibility of employers, regardless of fault § Used as a trial balloon for government-sponsored health insurance in US § But, the rise of private health insurance prevented a national health program Three Forces Created the Need for Health Insurance in America ü Technology § Advanced treatments became available, but they were expensive ü Social § Desirability of medical treatments ü Economic § Unpredictability of medical needs and costs of treatment Rise of Private Health Insurance ü 1911 – blanket insurance policies became available (life, sickness, accidents, nursing care) ü 1916-1918 – state employer mandates failed ü 1929 – Modern health insurance was born (Baylor Plan) § Established by J.F. Kimball for school teachers § At Baylor University hospital in Texas § A prepaid plan § Became the model for Blue Cross ü 1939 – The California Medical Association started the Blue Shield plan to cover physician services Private Health Insurance Became Employment Based ü WWII caused wage freezes § Employers started offering health insurance in lieu of wage increases ü 1948 Supreme Court decision § Legitimized health insurance as a negotiable item in union-management bargaining ü 1954 tax ruling § Employer contributions for health insurance became exempt from taxable income for the employee National Health Insurance: Actions Taken in the U.S. ü 1914 § Workers compensation ü 1917 § The American Association of Labor Legislation attempted to expand its social agenda by advocating national health insurance ü 1935 § Franklin Roosevelt era, New deal ü 1940s § Franklin Roosevelt: Bills on national health insurance failed to pass ü 1940s § Harry Truman: First US President to propose national health insurance ü 1992 - Clinton and Bush proposals - § Rising costs of health care and § Polls showed significant fear of loss of coverage and problems with receiving services Reasons for Defeated NHI Proposals in the U.S. 1. Political Inexpediency 1. No threat to US political stability a. Unlike Germany and England where social insurance was a way to get worker loyalty 2. US was decentralized a. Insurance matters were left to local and state governments 3. WWI a. A blow to NHI because of anti-German feelings b. Seen as a menace inconsistent with American values 2. Institutional Dissimilarities 1. Germany sickness funds not as developed in US 2. American hospitals mostly private a. Private hospitals not consistent with national financing b. Physicians saw a threat in shift from private to government pay c. Those opposed national health insurance i. American Medical Association ii. Insurance companies iii. Pharmaceutical companies iv. American Federal of Labor (AFL) d. Pharmaceutical companies feared government as a monopoly buyer e. Retail pharmacies feared being replaced by government established pharmacies f. Labor unions feared loss of influence in workplace i. AFL was the largest, most powerful union at one time 3. Ideological Differences 1. American beliefs and values a. Individualism b. Self-determination c. Distrust of government d. Reliance on private sector 2. Middle class support needed for broad reforms 4. Tax Aversion 1. Middle class already insured 2. Middle class favor helping others a. But not willing to pay increased taxes to cover it Creation of Medicare and Medicaid ü Before 1965, only private insurance was widely available ü Politicians believed there would be less opposition for programs targeted at the underprivileged § Only the working middle class had private insurance § The poor and elderly had to rely on own resources or charity § Private payers charged more to offset charity (cost shifting) § Social Security Amendments, 1965 created Medicare and Medicaid ü Precursors § Amy Forand’s bill (1957) to expand Social Security to include hospital and nursing home care for the elderly § Kerr-Mills Act (1960) gave federal grants to states to provide health care to low-income elderly § Rep. Byrnes’ proposal—Bettercare—premium cost sharing between the elderly and the federal government ü Medicare § Title XVIII of the Social Security Act (SSA) § Part A o Hospital and limited nursing home coverage (based on Forand’s bill) § Part B o Covers physician bills (based on Byrnes’ proposal to share the cost of premiums) § No class distinction § Uniform national standards for eligibility and benefits § Physicians could balance bill o Charge patient above set fees to recoup difference ü Medicaid § Title XIX of SSA § Federal matching funds to the states (based on Kerr-Mills Act) § For the indigent § Based on a means test developed by each state § Expanded to include all age groups, not just the elderly poor § Class distinction § Stigma of public welfare § Eligibility and benefits vary from state to state § Physicians cannot balance bill; limited participation from physicians Prototypes of Managed Care 1) Contract practice a. Capitation i. A contract with independent physicians and hospitals at a flat rate per worker per month (PMPM) b. Salaried physicians i. Both capitation and salary payments replaced fee-for- service c. The AMA approved contract practice only in remote areas (railroad, mining, and lumber enterprises) 2) Group practice a. Bringing physicians together with business managers and technicians in an elaborate division of labor b. Seen as a threat to general practitioners and specialists in solo practices c. Met with resistance by solo practitioners, but sharing of expenses and other economic advantages led to their growth 3) Prepaid group plans a. The AMA opposed the first plan in Washington, DC, but was found in violation of the Sherman Antitrust Act b. Soon, several plans started offering comprehensive services through organized general and specialist physicians c. One main limitation: It required sponsorship of large organizations The HMO Act of 1973 ü Increasing health care expenditures especially in the public sector (Medicare and Medicaid) ü Federal funds were made available to establish and expand HMOs (prepaid medical plans) ü The Act failed to achieve its objective, mainly because of apathy from employers Corporate Era: Late 1900s to Present ü General Agreement on Trade in Services (1995) § To remove barriers to international trade in services § In health care services, it may affect: • Health insurance • Hospital services • Telemedicine • Medical treatment abroad ü Three main features of the corporate era § Corporatization § Information revolution § Globalization ü Corporatization—medical care has become the domain of large corporations § High tech care in comfortable surroundings § But, cost control has remained unrealized § Managed care has become the primary vehicle for insurance and delivery • Consolidation of purchasing power on the demand side § Integrated health care organizations • To counteract managed care’s power • Hospitals expanded services in other areas to recoup lost revenues from reimbursement cuts in the 1980s § Physicians have consolidated into large clinics or hospital partnerships ü Information revolution § Telemedicine and telehealth • Integration of telecommunication systems into distant caregiving • Improves access in rural areas ü E-health • Information and services over the Internet • Has empowered consumers ü Globalization § Telemedicine § Medical tourism § Foreign direct investment in health care enterprises § Migration of health professionals § Overseas operations of US corporations § Overseas demand by US providers § Cross-border collaborations Corporate Medicine • Globalization has both positive and negative consequences Era of Health Care Reform Small incremental reforms: ü Children’s Health Insurance Program (CHIP) – 1997 ü Medicare Prescription Drug, Improvement, and Modernization Act, 2003, added Part D to Medicare Affordable Care Act: State Precedents ü Oregon Health Plan – late 1980s § Expansion of Medicaid § Supply side rationing § Medical insurance pool to cover preexisting medical conditions § Employer mandate ü Massachusetts Health Plan – 2006 § Individual mandate § Employer mandate § Government subsidies to low-income people § Insurance clearinghouse (Connector) Passage of the Affordable Care Act ü Patient Protection and Affordable Care Act, 2010 and Health Care and Education Reconciliation Act, 2010 ü Partisan legislation: Not a single Republican voted in favor ü President Obama united his own party behind the legislation ü Backroom deals were made with waffling members and interest groups ü The AMA reversed its historic stance in supporting the legislation ü The American public was kept in the dark about the details ü Legal challenges pushed the legislation before the Supreme Court The Supreme Court’s Ruling ü The majority of ACA provisions were ruled constitutional under the Congress’ power to tax (the individual mandate) ü However, the federal government could not coerce the states to expand their existing Medicaid programs The Aftermath ü Opposition to the law continues ü The Obama administration delayed implementation of the employer mandate until 2015 ü Several provisions of the law have been implemented since 2010, however, major implementation challenges continue ü The future remains uncertain.


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