Basics of the U.S

SECOND EDITION BASICS OF THE U.S. HEALTH CARE SYSTEM NANCY J. NILES, PHD, MS, MBA, MPH Associate Professor Lander University Greenwood, South Carolina 9781284034417_FMXX.indd 1 1/26/2014 12:01:57 AM World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]. 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Basics of the U.S. Health Care System, Second Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product. There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only. This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the service of a competent professional person should be sought. Production Credits Executive Publisher: William Brottmiller Publisher: Michael Brown Associate Editor: Chloe Falivene Editorial Assistant: Nicholas Alakel Production Manager: Carolyn Rogers Pershouse Senior Marketing Manager: Sophie Fleck Teague Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: Cenveo Publisher Services Cover Design: Scott Moden Director of Photo Research and Permissions: Amy Wrynn Cover Image: © avian/ShutterStock, Inc. Printing and Binding: Edwards Brothers Malloy Cover Printing: Edwards Brothers Malloy To order this product, use ISBN: 978-1-284-04376-1 Library of Congress Cataloging-in-Publication Data Niles, Nancy J., author. Basics of the U.S. health care system / Nancy J. Niles. — Second edition. p. ; cm. Includes bibliographical references and index. ISBN 978-1-284-03441-7 (pbk.) I. Title. [DNLM: 1. Delivery of Health Care—United States. 2. Insurance, Health—United States. 3. Government Programs— United States. 4. National Health Programs—United States. W 84 AA1] RA445 362.1--dc23 2013035792 6048 Printed in the United States of America 18 17 16 15 14 10 9 8 7 6 5 4 3 2 1 9781284034417_FMXX.indd 2 1/26/2014 12:01:57 AM Contents About the Author ix Acknowledgments xi Preface xiii Chapter 1 History of the U.S. Healthcare System 1 Learning Objectives 1 Did You Know That? 1 Introduction 1 Consumer Perspective on Health Care 2 Milestones of Medicine and Medical Education 3 Milestones of the Hospital System 5 Milestones of Public Health 5 Milestones of the Health Insurance System 10 Current System Operations 11 Assessing Your Healthcare System Using the Iron Triangle 12 Conclusion 12 Vocabulary 13 References 14 Notes 16 Student Activities 17 Chapter 2 Impact of the Affordable Care Act on Healthcare Services 27 Learning Objectives 27 Did You Know That? 27 Introduction 27 Major Provisions of the Affordable Care Act 28 Conclusion 37 Vocabulary 37 References 38 Notes 41 Student Activities 42 Chapter 3 Current Operations of the Healthcare System 53 Learning Objectives 53 Did You Know That? 53 iii 9781284034417_FMXX.indd 3 1/26/2014 12:01:57 AM Contents Introduction 53 Overview of the Current System 54 Major Stakeholders in the Healthcare Industry 54 Stakeholders’ Environment 57 Healthcare Statistics 57 Conclusion 87 Vocabulary 87 References 88 Notes 90 Student Activities 91 Chapter 4 Government’s Role in U.S. Health Care 101 Learning Objectives 101 Did You Know That? 101 Introduction 101 History of the Role of Government in Health Care 102 U.S. Government Agencies 102 Conclusion 107 Vocabulary 108 References 108 Notes 111 Student Activities 112 Chapter 5 Public Health’s Role in Health Care 123 Learning Objectives 123 Did You Know That? 123 Introduction 123 What is Health? 124 Primary, Secondary, and Tertiary Prevention 125 Origins of Public Health 125 What is Public Health? 126 The Epidemiology Triangle 127 Epidemiologic Surveillance 127 Environmental Health 128 Emergency Preparedness 129 State and Local Response to Disasters 130 Bioterrorism 131 Public Health Functions and Administration 132 Healthy People Reports 133 Public Health Infrastructure 134 Government Contributions to Public Health 134 Nongovernment Public Health Activities 135 Public Health Education and Health Promotion 136 Collaboration of Public Health and Private Medicine 138 Conclusion 139 Vocabulary 139 References 140 Notes 143 Student Activities 144 iv 9781284034417_FMXX.indd 4 1/26/2014 12:01:57 AM Contents Chapter 6 Inpatient and Outpatient Services 155 Learning Objectives 155 Did You Know That? 155 Introduction 155 History of Hospitals 156 Hospital Types by Ownership 157 Hospital Types by Specialty 157 Other Hospital Classifications 157 Hospital Governance 158 Hospital Licensure, Certification, and Accreditation 158 Patient Rights 159 Current Status of Hospitals 159 Outpatient Services 160 Other Health Services 162 Conclusion 164 Vocabulary 165 References 166 Notes 169 Student Activities 170 Chapter 7 U.S. Healthcare Workforce 181 Learning Objectives 181 Did You Know That? 181 Introduction 181 Primary, Secondary, and Tertiary Care 182 Physician Education 182 Generalists and Specialists 183 Differences Between Primary and Specialty Care 183 Patterns of Physician Supply 183 Types of Healthcare Providers 184 Other Independent Healthcare Professionals 186 Allied Health Professionals 187 Non-CAAHEP Allied Health Professionals 191 Conclusion 192 Vocabulary 193 References 194 Notes 197 Student Activities 198 Chapter 8 Healthcare Financing 209 Learning Objectives 209 Did You Know That? 209 Introduction 209 Healthcare Spending by Service Type 210 Healthcare Spending by State 211 Health Insurance as a Payer for Healthcare Services 211 Types of Health Insurance 212 Cost Sharing of Health Services 213 Types of Health Insurance Policies 213 Types of Health Insurance Plans 213 v 9781284034417_FMXX.indd 5 1/26/2014 12:01:57 AM Contents Public Financing of Healthcare Services 215 Reimbursement Methods of Private Health Insurance Plans 218 Government Reimbursement Methods for Healthcare Services 219 Healthcare Financial Management 221 Funds Disbursement 222 Conclusion 222 Vocabulary 222 References 224 Notes 226 Student Activities 227 Chapter 9 Managed Care Impact on Healthcare Delivery 237 Learning Objectives 237 Did You Know That? 237 Introduction 237 History of Managed Care 238 Managed Care Characteristics 239 The Managed Care Organization Payment Plan 240 Cost Control Measures of Managed Care Organizations 240 Medicare and Medicaid Managed Care 241 Assessment of Managed Care Models 242 Managed Care Accreditation 243 Issues with Managed Care Operations 243 Conclusion 243 Vocabulary 244 References 245 Notes 247 Student Activities 248 Chapter 10 Information Technology Impact on Health Care 259 Learning Objectives 259 Did You Know That? 259 Introduction 259 History of Information Technology in the Healthcare Industry 260 Electronic Patient Records 261 Barriers to Electronic Health Record Implementation 262 Primary Care Information Project in New York City Model 263 Clinical Decision Support Systems 264 Computerized Physician Order Entry 264 Pharmacy Benefit Managers 265 Drug–Drug Interactions 265 Telehealth 265 Chief Information Officer 266 Council for Affordable Quality Health Care 266 Other Applications 267 Applied Health Information Technology 268 The Importance of Health Information Technology 269 Conclusion 270 Vocabulary 270 vi 9781284034417_FMXX.indd 6 1/26/2014 12:01:57 AM Contents References 271 Notes 274 Student Activities 275 Chapter 11 Healthcare Law 285 Learning Objectives 285 Did You Know That? 285 Introduction 285 Basic Concepts of Healthcare Law 286 Tort Reform Discussion 286 The Legal Relationship Between the Provider and Consumer 287 Healthcare-Related

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