Mahatma Gandhi the Issue of Healthcare Is

INTRODUCTION

It is health that is real wealth and not pieces of gold and silver -Mahatma Gandhi

The issue of healthcare is frequently debated worldwide. Because citizen health is a top priority for nearly every government worldwide, its experts perform much research to discover the most efficient and effective means of providing quality health care services to their community members. Specifically, the non-metropolitan healthcare sector continues to present difficulties for a country’s healthcare system.

In order to reveal potential solutions to the problems of non-metropolitan healthcare, this thesis will investigate the health care services that are provided to communities of this type. Comparing and contrasting the health care provided by Blount

Memorial Hospital of East Tennessee with that of health care in the Chinese city of

Shangri-La, will provide a case study to discover potential health care improvements. It will first examine the common injuries and illnesses that are prevalent in these communities, to reveal the demand for services of the citizens in the community. Next, it will discuss the health care services that are provided by health care facilities both internally and externally, thus, disclosing the way each community has chosen to supply services for their respective citizens. Then, it will analyze the quality care issues that ensure that the hospital provides a high standard of medical treatment to citizens. Finally,

it will evaluate the accessibility of these services to citizens in the community by displaying time-efficiency as well as the affordability of health care treatment.

Once all of the data is analyzed and discussed, the thesis will suggest potential solutions that could improve the health care of each community. This structure of research will allow both positives and negatives of each system to be exposed and will yield beneficial solutions that each of the facilities could adopt as policy or procedure.

Through the research of health care facilities in both non-metropolitan areas of United

States and China, each health care organization will be able to view areas in which they succeed and areas where they could improve.

CHAPTER I

DEMAND FOR HEALTH CARE

When it comes to health simply eat less -Confucius

Consumers of a particular community create the demand for health care.

Consumer demand stems from community members requiring healthcare treatment for the countless injuries and illnesses that individuals are likely to experience. Demands for health care vary for different geographical regions within a country. The demand for health care for both United States and Chinese non-metropolitan cities are the focus for this particular study. Accordingly, a brief historical background is necessary to effectively analyze each region. Also, the definitions of crucial terms provide clarity for this particular research topic.

One of the locations that will be used for comparison for this thesis is Blount

Memorial Hospital that is located south of Knoxville at the foothills of the Appalachian

Mountain region in East Tennessee. This healthcare organization is in continuous competition for resources and consumers (patients) against other health care facilities in the region. Blount Memorial Hospital was founded in 1947 as one of thirteen original county-chartered hospitals statewide. The combined efforts of many community members and businesses led to the creation of Blount Memorial Hospital. It opened July

24, 1947, and was named in honor of all the Blount Countians who served in the United

States’ armed forces. Since its opening, Blount Memorial has confronted the task of providing quality healthcare services to a once isolated community. Over time as the community has grown, Blount Memorial has chosen to broaden its services and capacity in order to accommodate the increasing demand from the community (Blount Memorial

Hospital).

Today, of the original thirteen hospitals chartered in Tennessee, Blount Memorial is the only one that remains owned by the community; larger private healthcare systems purchased the bulk of community hospitals. Blount Memorial currently has a 334-bed capacity and serves the citizens of Blount County as well as other four other surrounding counties (Blount Memorial Hospital). Figure 1 shows that Blount County is located in the Southeast region of Tennessee.

Figure 1: Tennessee County Map Source: “Tennessee County Map”

The other location for the study is the city of Shangri-La located in the southwest

Yunnan province of China. This city has a population of approximately 30,000 residents comprised mostly people of Tibetan ancestry (Briggs). This area of China relies heavily upon the tourism industry for economic prosperity. Much as Maryville is the so-called gateway to the “Smoky Mountains,” Shangri-La is a gateway to the Himalayan

Mountains.

During China’s Cultural Revolution of the 1960s, the Chinese government instituted a healthcare system that specialized in cheap preventative healthcare to citizens through a group of people known as barefoot doctors. Barefoot doctors were both selected and trained by government officials; afterwards, barefoot doctors provided preventative health care education to members of rural communities. This grassroots program had great success up until the 1980s when funding was cut by the Chinese government in anticipation that capitalism would be able to provide adequate healthcare services to the Chinese citizens (Brant et al.).

Over the next two decades the healthcare system declined rapidly in remote areas.

Shangri-La was amongst the many regions that suffered during this time. Geographic remoteness, lack of funding, and increasing medical costs made healthcare highly inefficient and unaffordable. Thus, by 2006, healthcare services were minimal at best in these areas (Brant et al. 2-4). Figure 2 is a map of China broken into the numerous provinces. The city that will be used for the purpose of this research is located in the

Yunnan province in the southwest region (Brant et al.).

Figure 2: Map of Chinese Provinces Source: “Chinese Province Map”

When discussing healthcare issues there are certain terms that are used

ambiguously in common conversation; therefore, for clarity purposes, these terms will be

defined to attach specific meaning for the purpose of this research. These terms will be

used throughout the duration of the report and can be referenced in Table 1 below.

TERM DEFINITION Accessibility The ability of citizens to receive the necessary healthcare services External Services Services provided away from the main healthcare facility campus Health Care Institution The healthcare facility or hospital itself Health Care System The healthcare facility and all other organizations that stem from the main facility Internal Services Practices that are performed within main healthcare facility Non-Metropolitan Region An area in which all cities have less than 50,000 citizens OSHA Federal agency that enforces health and safety regulations for American hospitals Quality Care The expectations that citizens have towards hospital facility and personnel Rural Region The population of an area of which there are 2500 citizens or less Cost-Shifting Process of increasing prices from one party to the next to offset costs

Table 1: Definition of Health Care Terms Source: Sumaya

The first step necessary to compare and contrast the health care systems of both

Blount County, Tennessee, and Shangri-La city of rural China will be to examine common injuries and illnesses that warrant the need for health care services. These ailments are the equivalent to the consumer demands of modern businesses. The most common injuries and illnesses that citizens of their respective communities experience are the driving force that dictates the appropriate health care services to be provided by the respective health care facility. This comparison will reveal both similarities and differences for the demand determinants for healthcare treatments in both Blount County and Shangri-La.

Blount County: Demand for Health Care

Non-metropolitan areas, such as Blount County, possess unique health statistics that differ greatly from other parts of the United States. As of 2004, Blount County ranked fourth in the state of Tennessee for total number of accidental deaths (“Tennessee

Health Statistics”). A study performed by the U.S. Department of Health and Human

Studies found, in the year 2000, the most common cause of death for Blount County citizens between the ages of 15 and 44 was due to injury. In 2001, the Center for Health

Statistics completed research about Blount County that discovered a listing of common injuries within the community. Injuries that occurred with most frequently were motor- vehicle related, suffocation, poisoning, fire, falls, and drowning. These injuries resulted in a total of twenty-seven deaths and nearly half of which were motor vehicle related.

The remainder of the death resulting injuries yielded no more than two over the course of the year. However, not all injuries have such dismal results (Community Health Status

5).

The largest majority of injuries is quite treatable and simply requires minor medical attention. Therefore, the next area of focus will discuss common causes for emergency room visits at Blount Memorial Hospital for the month of March in 2008. In

2007, Blount Memorial reported over 50,000 emergency rooms visits (Annual Board

Report 11). Studies have shown that citizens who perform tasks that involve heavy lifting, over 20 pounds, or repetitive movements are most likely to incur sprains and strains, mostly in the back region (Ricketts 641). After viewing data from the Blount

Memorial emergency department, it becomes quite clear that back problems are frequently a cause for injury in this community. In fact, of the top 75 diagnoses upon entry into the emergency department, there are six different categories designated for back injuries. If all back pain ailments were lumped into one category, it would render over 1800 cases in a single month for Blount Memorial. Other injuries that occupy the top of the diagnosis list are lacerations, contusions, and wound/suture checks. Due to the fact that Blount County has numerous bodies of water and agricultural settings, citizens of this community are an increased risk of enduring outdoor injuries (“Emergency

Department Statistical Report”).

Studies based on settings similar to those of Blount County found citizens who perform agricultural work or are around heavy machinery have the highest rates of machinery-related injuries and death. Most injuries occurring in this particular area of work are due to collisions on tractors or being cut with sharp pieces of machinery. The youth who work in agriculture are at a high risk of injury as well. Even though youth make up a small percent of the work force population, they account for nearly half of the work-related fatalities among minors (Castillo and Alexander 2). Studies suggest that the

time when a young person is most likely to be injured on the farm is between the ages of eight and fourteen. These injuries parallel rural communities throughout the United

States. In rural and non-metropolitan area in 2001, 70 children under the age of 14 were killed from injuries while on a farm. In that same year children, while on a farm, incurred over 22,000 injuries. Most of these injuries stem from two major sources: machinery and animals. One out of every five youth related injuries occurring on farms are through encounters with animals, mostly horses. Children under the age of 6 are more likely to be injured from falls whereas children 6-12 are more likely to be injured from the misuse of farm equipment (National SAFE KIDS Campaign).

Work-related injuries are also present in the Blount County area, especially with a majority of its workforce employed in factories or agriculture. Therefore, it is necessary to also discuss health statistics that are reported to the Blount Memorial Occupational

Health Center. This particular facility focuses on injuries and illnesses that are acquired while at work. Based on findings from companies that utilize such services,

Occupational Health formulated a top ten injuries list that consists of the following injuries, in order from most likely to least likely: open wound (fingers/thumb), sprain/strain to upper arm and shoulder, sprain/strain to lumbar, sprain/strain to wrist, sprain/strain to knee and leg, low back pain, hearing loss, eye damage, and Carpel Tunnel

Syndrome. Accordingly, it can be deduced that jobs that involve sharp objects, heavy lifting, and repetitive movements place workers at a higher risk for injury (Business

Health and Occupational Health Center 1). Although this list of injuries does not include every particular injury that can possibly occur, this list is comprised of the most common injuries viewed by the Blount Memorial emergency department, Occupational Health, as

well as other injuries common to areas in the United States that are similar in nature to

Blount County. In 2007, it was reported by the American Hospital Association that hospitals nationwide treat nearly 118 million people in the emergency department and provide care to over 481 million outpatients every year, which is approximately 1.5 visits per United States citizen. In the vast majority of these hospitals, common injuries such as those of Blount County are the most frequent reason for a visit to the emergency department ("Health and Hospital Trends").

Illnesses common to the Blount County community also contribute to the overall demand for health care services. The 2001 Blount County health report listed the following diseases as the most prevalent in Blount County: heart disease, cancer, stroke, chronic lower respiratory disease, influenza/pneumonia, and Alzheimer’s disease. Upper respiratory cancers were the most common in Blount County followed closely by breast and prostate cancer (Blount County Health Profile 13). When compared to peer counties,

Blount County has higher than expected rates of illness for coronary heart disease, lung cancer, and stroke (Community Health Status 6).

Blount Memorial’s emergency department further confirms the presence of these common illnesses in the community as well as others. In March 2008, the diagnoses for the highest number of emergency room visits were chest pains, over 1800. Abdominal pain ranked a close second with over 1600 diagnosis in a single month. Third was nausea and vomiting with over 1100 cases, and fourth was pneumonia with just over 1000 cases.

These four illnesses exceeded all other ailments by at least 200 cases during this particular month. Other common illnesses that made the top 75 diagnosis list included bronchitis (794 cases), upper respiratory infection (292 cases), fever (190 cases), and

influenza (156 cases) (Top 75 Diagnosis). Table 2 lists top diagnoses for Blount

Memorial Hospital.

Table 2: “Top 75 ER Visits: March 2007” Source: “Emergency Department Statistical Report”

By comparing Blount County to the state of Tennessee, it becomes clear that

Blount County nearly parallels the common illnesses that affect Tennesseans. In 2005, a study for Tennessee discovered that the top illnesses that resulted in death for the male population were as follows: heart disease, malignant neoplasm (cancer), obesity, influenza and pneumonia, Alzheimer’s, and chronic liver disease and Cirrhosis. Heart disease was the leading cause of all deaths in the state of Tennessee in 2005, claiming the lives of nearly 8,000 men statewide. However, heart disease has been on the decline for

Tennesseans in recent years declining nearly seventeen percent since 1996. This decline in heart disease has been credited to individuals who have stopped smoking, increased physical activity, and consumed a healthier diet. Cancers claimed the second most lives of Tennessee males in 2005, nearly 7,000. The most common types of cancers were upper throat and respiratory, prostate, colon, pancreas, and non-Hodgkin’s lymphoma. It is also important to mention that nearly all of these illnesses present increasing rates of occurrence over the last ten years with the exception of heart disease which has been on a four year decline (“Tennessee Health Statistics”).

Similar to common injuries, information from the Occupational Health Center was taken into account when covering common illnesses. Occupational Health was able to tabulate the most frequent illnesses that trouble Blount County employees while on the job. The top illnesses in no particular order include the following: upper respiratory infections, elevated blood pressure, cardiovascular disease, Tuberculosis, and substance abuse (Business Health and the Occupational Health Center 4). As apparent, most of the common illnesses overlap from people on the job to those of citizens in the community.

A report released by the Center for Disease Control and Prevention listed national work-

related illnesses and injuries for the 2003-2005 period. This data confirms that workers are not experiencing as many injuries or illnesses while on the job. Over this three-year span the number of injuries and illnesses has decreased from 2.3 million cases to 2.1 million cases. The specific job types that are associated with a higher risk of injury or illness include construction, manufacturing, wholesale trade, and transportation (United

States).

The main culprit for both heart disease and cancers in Tennessee is smoking. The number of smokers and substance abusers in the Blount County area has always been a concern for this particular area, and the illnesses which plague the area reflect the poor health decisions many citizens in the area are making (Castillo and Alexander 5). The

Center for Disease Control and Prevention has collected national data on smoking percentages for males, females, high school students, and pregnant women since 1965.

During this time, males have decreased smoking by the greatest percentage dropping form over 50 percent in 1965 to around 23 percent in 2005. Women have decreased over the same period from 33 percent to 18 percent. High school students increased their percentage of smokers in the late 1990s to decrease dramatically to 21 percent in the

2004. Pregnant women have also decreased the amount of smoker from around 20 percent in the 1980s to around 10 percent in 2005. These overall declines in smoking have led to decreases in heart disease, cancer, and other smoking-related ailments (United

States).

On even a larger scale, this data resembles the national health statistics very closely. A report released in March 2008 revealed that the leading causes for death in the

United States in descending order are as follows: heart disease, malignant neoplasms,

cerebrovascular disease, chronic lower respiratory disease, diabetes, influenza and pneumonia, and HIV infection (United States). By far the top two ailments claim a significantly greater number of lives. Even though Blount County is unique with certain aspects of its health care situation, many of the same ailments are similar to those of nearly every other region of the United States.

The last cause that requires healthcare attention is births in the community. In

2007, there was a reported 913 births that took place at Blount Memorial, an increase of nearly 16% from the previous year (Annual Board Report 11). This is compared to the 4 million births that occurred in 2007 throughout the entire United States (“Health and

Hospital Trends”). The U.S. Department of Health and Human Services performed a study that revealed that Blount performs well in regards to infant mortality rate, low birth weights, premature births, and no care in the first trimester when compared to peer counties. However, some areas where Blount County can improve include the number of teen mothers and the number of older mothers, over the age of 40 (Community Health

Status 6). An overview of the Blount County health statistics in 2001 found that for the estimated number of female pregnancies, over 20% consisted of unmarried mothers, a rate much higher than that of peer counties (Blount County Health Profile 12). Time series data from the Center for Disease Control and Prevention have tracked national birth rates for women since the 1950s. These statistics show that births for women ages

10-17 have gradually decreased since the 1950s each decade to reach the lowest rate in the last 55 years. However, births for women ages 40-44 have nearly tripled since 1985

(United States).

Shangri-La: Demand for Health Care

Now that the sources of health care demand for Blount County have been examined, a similar discussion of the Shangri-La community will ensue. It is important to note that much of the information regarding the Chinese health care system was obtained first-hand while the researcher, Cory Everett, spent time in China studying the

Chinese health care system. During the study, actual experts of Chinese healthcare were interviewed and provided a bulk of the region-specific information that would have been otherwise unavailable to the researcher from the United States. One of the main sources of information came from an in-depth interview with an American doctor who had been living and working in China for nearly two decades. Dr. Douglas Briggs is a graduate of the University of Tennessee, as well as the University of North Carolina Chapel Hill

Medical School. Dr. Briggs provided tremendous insight into the Chinese health care system that would have been quite inaccessible for most foreign researchers (Briggs).

In order to effectively analyze the Chinese health care system, the sources of health care demand were the first point of research emphasis so that a comparison to

United States health care demand could be made. Common ailments for the Shangri-La community include an array of injuries that range from automobile accidents to recreational injuries. Geographically, the city of Shangri-La is not very large in landmass; thus, the majority of the population is confined within a small area. Due to the economic structure of the city, the streets are lined with numerous shops and market areas. Accordingly, there is a mass of pedestrian traffic that bustles up and down city sidewalks. There is also a high number of automobile traffic stemming from the movement of tourists throughout the city. These are the factors that appear to be the

main culprit for the high number automobile-related accidents. According to Dr. Briggs, a high majority of his patient load is a direct result of an automobile-related accident.

Injuries for such accidents include lacerations, contusions, head injuries, and broken bones (Briggs).

The other major reason for injuries within the community comes from recreational activities. Because of Shangri-La’s proximity to numerous Himalayan

Mountains, outdoorsmen from all over the globe flock to the area to enjoy the activities and scenery. Consequently, with this increasingly high number of outdoorsmen visiting the area, many expect the likelihood of outdoor-related accidents to increase (Everett).

Common recreational injuries include: sprains, strains, broken bones, burns, and wildlife- related accidents. These injuries usually increase in the summer months when weather is warmer as well as the early winter when the snow is just beginning to fall on the mountains. Work-related injuries are also common in Shangri-La. Burns resulting from working around fires, stoves, and ovens are the main causes of injury for restaurant workers. Chinese agricultural workers experience similar injuries to American citizens, including strains, sprains, and lacerations that stem from repetitive use of farming equipment and physical labor. Currently, automobile injuries occur frequently in

Shangri-La because most citizens are accustomed to low levels of automobile traffic.

However, as citizens become more aware of the dangers that coincide with more automobiles in the area, traffic-related injuries are expected to decline. Improvements to traffic signage may also reduce the number of automobile-related accidents. Restaurant workers are also exposed to specific health dangers because it is a cultural norm in China

to cook over open flames, especially in restaurants, which places the employees at a greater risk for burn injuries (Briggs).

Illnesses that are common in Shangri-La are tuberculosis (TB), upper respiratory infections, influenza, and intestinal infections. Tuberculosis, according to Dr. Briggs, is the one illness that has burdened the Shangri-La citizens the most. Dr. Briggs believes that the reason that TB is such a problem for the citizens is due their propensity to spit.

In Chinese culture, the norm has been to spit out any type of respiratory congestion. In some cases, this is an effective way to rid the body of unwanted germs and bacteria that the body is fighting against. However, for individuals that have TB it can be a severely bad habit. Tuberculosis can survive in saliva for approximately one month even after leaving the body. Thus, the likelihood of other citizens contracting TB increases significantly, especially members of the same household. Another problem that occurs with TB is that, while some cases of TB are curable with the appropriate medication, many citizens; do not continue the medication for the recommended time. This allows

TB to become resistant to the medication and then becomes a much more serious illness

Multi-Drug Resistant Tuberculosis (MDR-TB). Reasons for citizens not completing the recommended dosage cycle will be given in the accessibility section of the health care system. Area physicians are trying to combat the TB problem before MDR-TB becomes widespread within the community. If health care professionals are able to educate and persuade the citizens on the dangers of spitting and encourage annual TB testing, this particular ailment could be expected to decrease in the future. Also regular check-ups with medical personnel could significantly reduce the length and frequency of hospital visitations (Briggs). Table 3 depicts the improvements that have been made regarding

TB awareness. Directly observed treatment strategy (DOTS) is a method used to implement medical examinations and screening for large scale medical problems. As shown in the graph, from 1991-2005 the amount of TB awareness and testing increased a considerable amount over this frame of time. Currently, in Shangri-La, TB remains to be a problem because individuals are not completing the recommended length of dosage.

Proportion (%) of new smear- Estimated proportion (%) of all Proportion (%) of counties Year positive TB cases successfully new smear-positive TB cases implementing the WHO-recommended treated detected DOTS strategy

1991 69 4 5

1992 75 7 7

1993 79 10 19

1994 88 14 48

1995 92 21 58

1996 94 25 60

1997 94 26 61

1998 93 27 62

1999 92 28 63

2000 92 30 63

2001 91 29 65

2002 91 26 64

2003 92 44 77

2004 90 63 89 2005 90 80 100

Table 3: TB Awareness in China Source: “Stopping Tuberculosis in China”

Comparison About the Demand for Health Care

After reviewing common injuries and illnesses for both Blount County and

Shangri-La, several similarities and differences are apparent. First, there exist geographical similarities between these two regions. Both areas are situated in the foothills of mountainous regions and provide some causation for the injuries and illnesses that are associated with such locations. It comes as no surprise that both are renowned for their respective outdoor recreational opportunities. Accordingly, specific injuries such as sprains, strains, and other injuries resulting from falls place residents and tourists at an increased risk for such occurrences (Everett).

Another similarity is that both areas have an elevated occurrence for work-related injuries. Agricultural work is present in both Blount County and Shangri-La, and because many residents seek employment in this particular sector of work, they share a common set of medical problems that are directly correlated with agricultural labor. For example, both locations have a higher occurrence level of orthopedic ailments, mostly back-related. This is due to the frequency of heavy lifting that is associated with agricultural work. It seems to follow that the Chinese citizens would have a much higher risk for back ailments due to the lack of farming equipment that is used for heavy lifting

(Everett).

Another similarity is that both regions share a few of the common illnesses.

In both communities, influenza is common mostly due to the similarities in climate although Shangri-La’s average temperatures are somewhat lower on average than that of

Blount County. Another common illness involves the upper respiratory system.

However, observation and personal knowledge seem to suggest that where Blount County citizens are currently feeling the negative health effects of continuous smoking, Shangri-

La citizens seem to just be beginning this negative cycle. Shangri-La, as well as the rest of China, has seen its citizens, over the past decade, become increasingly addicted to tobacco products, especially male citizens (Everett). As of 2006, nearly 70 percent of adult males in China were tobacco users compared to the 21 percent of United States male users. Chinese women are now too beginning to use tobacco products at an increasing rate, 4% of the Chinese female population were classified to have a “smoking prevalence” which ranks China second out of a polled forty-three countries among women smokers (“Chinese Health Statistics”).

However, there are also differences between the two locations regarding demand for health care. In Shangri-La there seems to be an increased occurrence of stomach ailments that stem from unsanitary conditions that continue to burden its residents still in

2008. In fact, only 27% of its China’s rural population has access to adequate sanitation facilities. Furthermore, only 66% of China’s rural population has access to improved drinking water sources (“Chinese Health Statistics”). This is one area, in particular, that the United States far surpasses the Chinese. In the United States, 100% of the population, including rural, has access to both adequate sanitation and improved water sources.

Another area where the two communities differ somewhat is the prevalence of certain ailments. China seems to have few occurrences of obesity whereas it is a tremendous burden in the United States, but on the flip-side China has a much greater occurrence of malnutrition than the United States. Diabetes is also a common illness in

the United States that does not have much of a presence in China. In contrast, Shangri-La in particular has a tremendous problem regarding tuberculosis. This is a direct result from certain cultural norms such as spitting which is nearly a universal action among all

Chinese citizens. Consequently, tuberculosis can survive in a saliva sample after leaving the body for up to one month that places citizens, especially family members, at an extremely high risk of contracting the ailment (Everett). Another similarity is the two regions prevalence to HIV. China as a whole has one of the lowest rates of HIV among its adult citizens, less than 1% of its population. Similarly, Blount County has one of the lowest rates of HIV/AIDS in the state of Tennessee, less than 100 cases reported since

1992 (Blount Country Health Profile). These similarities and differences regarding the demand for health care services result in many of the similarities and differences that will follow in the health care services provided by each respective community.

CHAPTER II

SUPPLY OF HEALTH CARE SERVICES

The superior doctor prevents sickness; The mediocre doctor attends to impending sickness; The inferior doctor treats actual sickness -Chinese Proverb

Supplying services in order to meet the demands of consumers is always priority for any successful business; health care facilities are no exception. Services are subdivided into internal services and external services. Analyses of both service types provide insight to the approach that specific health care systems implement to meet the demands of the community. Ultimately, a comparison will reveal the similarities and differences between the supplies of services the different locations offer to meet the demands of their respective consumer markets.

Blount County: Health Care Services

Internal services make up a majority of traditional features that one might expect a hospital to include. The emergency department is obviously one of the most active of the areas in the hospital due to its high volume and rapid patient turnover rate. Other services that are made available in Blount Memorial include the following: cancer center, radiology, laboratory, rehabilitation, weight management center, surgery, and family birthing center (Blount Memorial Hospital).

As previously discussed, Blount County citizens have been at an elevated risk for suffering from the various types of cancers. Accordingly, Blount Memorial provides the necessary medical treatment through its state-of-the-art cancer center, opened in 2005.

By incorporating the latest technology and skilled physicians, Blount Memorial is able to diagnose and treat patients effectively. It boasts such amenities as the latest mammography machinery and CT scanners. This technology complements the team of oncologists, surgeons, radiologists, urologists, gastroenterologists, dermatologists,

OB/GYNs, and pathologists who specialize in cancer care (Blount Memorial Hospital).

The radiology center at Blount Memorial is one department that is, by nature, intertwined with nearly every department within the hospital. Every department at the hospital requires a broad scope of services from the radiology department, ranging from using x-ray to view broken bones to performing an ultrasound on an expectant mother

(Blount Memorial Hospital). In 2007, medical staff ordered 124,662 radiology exams for both inpatient and outpatient cases (Annual Board Report 11).

Blount Memorial’s laboratory has the responsibility of performing all necessary lab work for the entire hospital. This can range from taking blood samples to evaluating

Tuberculosis tests (Blount Memorial Hospital).

The rehabilitation center at Blount Memorial provides an area for recovering patients to exercise and regain strength after medical procedures. This particular area is also available to community’s members who wish to improve their health under professional supervision (Blount Memorial Hospital).

The weight management center is a new service that became an independent department in 2007. Its specialty services are designed to help those who struggle with obesity or other weight-oriented ailments. This program utilizes the expertise of a certified dietician as well as physical therapist so that individuals can improve their health conditions through a comprehensive weight management program (Blount

Memorial Hospital).

The surgery center is another area of high volume. Blount Memorial surgeons performed over 6,000 surgical cases in 2007 (Annual Board Report 12). Blount

Memorial’s surgery center is capable of performing general surgeries as well as the more complicated vascular and cancer surgeries. Other specialized surgeries include colon and rectal, podiatry, plastic, orthopedic, eye, endoscopic, gynecological, urological, ear, nose and throat. Bariatric surgery is also now available at Blount Memorial (Blount Memorial

Hospital).

Similar to the surgical center, the family birthing center also assists with numerous births annually. In 2007, a total of 913 deliveries took place at Blount

Memorial hospital, an increase of nearly 200 from 2006 (Annual Board Report 11). The

family birthing center at Blount Memorial attempts to aid new parents during the transition to parenthood as smoothly as possible. Blount Memorial provides new parents classes and help services both before and after children are born. To make the birthing process a pleasant experience, the family birthing center provides large home-style rooms so that families can have their privacy as they bond with their newborns (Blount

Memorial Hospital).

External services comprise the remaining services that Blount Memorial offers.

Most of these services were later additions and originated from the changes in community members’ demands. External services include: the Good Samaritan Clinic,

Springbrook Wellness Center, Morningview, Hospice, and Occupational health (Blount

Memorial Hospital).

Blount Memorial’s Good Samaritan Clinic serves as a primary care facility that was founded in 1997 as a part of the hospital’s 50th anniversary. This clinic assures that everyone in the community can receive quality health care. This clinic provides services to those in the community who are underserved or uninsured. In 2007, the Good

Samaritan Clinic treated over 14,000 patients, over 9,000 adults and 5,000 children

(Annual Board Report 12). This clinic is funded mostly by Blount Memorial Foundation through various forms community fundraising events and has been operating successfully for over a decade. Aside from benefiting citizens in the community, Blount Memorial has also seen a decrease in waiting times in the emergency department by attracting less serious cases to the Good Samaritan Clinic. Thus, this external innovation has provided quality services to the underserved and decreased the waiting time for care in the emergency department (Blount Memorial Hospital).

The Springbrook Wellness Center is the next external service that earns merit.

This 30,000 square foot facility combines the latest fitness technology with a medically trained staff to provide a means to teach healthier lifestyles, treat the source of poor health that leads to disease, and increase individuals’ personal outlook through greater fitness. This facility focuses on preventative healthcare treatment to combat health issues that frequent our community. In 2007, the Springbrook Wellness Center had over 3,300 memberships, an increase of over 100 memberships from the previous year (Annual

Board Report 12).

The Morningview assisted living facility is another external service that meets the demands of the Blount County community (Blount Memorial Hospital). With over

17,000 citizens over the age of 65 in the Blount County area, this facility meets the high demands of health care services for this particular growing population in the community

(Blount County Health Profile 12). In addition, the Morningview facility provides a professionally trained medical staff that makes this specific facility such a vital contribution to the external services of Blount Memorial. This facility provides elderly individuals a place to reside under the discreet observation of medical personnel.

Morningview also contains a specific area for individuals coping with Alzheimer’s disease as well as other mental disorders common with the aging process. In 2007,

Morningview Village provided assisted living residency to nearly 90 individuals (Annual

Board Report 12).

Founded in 1981, the Hospice care program provides services to individuals and their families who are coping with terminal illnesses. This service provides both health care and emotional care to make the passing of family members as easy as possible.

Services within the Hospice program include: pain relief and symptom management, support from trained volunteers, intermittent nursing and home care aide visits, in-home counseling, social work, and spiritual support for patients and families. In addition, physical, occupational, and speech therapy services are provided so as to allow the patient to enjoy the highest quality of life possible (Blount Memorial Hospital).

The last external service is the Occupational Health Center. As previously discussed, this service is directed towards community employers who wish to lower healthcare costs by utilizing health care services from Occupational Health professionals.

The first approach of an on-site nurse incorporates the services of either part-time or full- time nursing care at the business facility itself. With this option is included employee return-to-work follow-ups, compensation claims paperwork, and health and safety education. The second service is a health and safety program. This particular program focuses on improving health care in the employer’s worksite using people with a medical background. A team of trained professionals will implement services such as health and safety programs, health screenings, and personal health education. The next program of occupational health is consultation services. This approach provides suggestions to companies of possible methods to improve the health of employees. The fourth program provided by occupational health is the direct services of the Occupational Health Center.

As a part of this program, companies are provided pre-placement examinations, on-the- job injury and illness evaluations, drug and alcohol testing, ergonomic evaluations, compliance with OSHA regulations, and on-the-job illness evaluations. The fifth and final program implements the rehabilitation services that the Occupational Health Center has to offer. This program allows injured and sick employees to receive treatment as well

as rehabilitation treatment (Health Care for Business and Industry). This information suggests that Blount Memorial is attempting to meet changing consumer demands by implementing new facilities and services as health problems emerge.

Shangri-La: Health Care Services

Healthcare services in Shangri-La have undergone much change in accordance to the increasing numbers of tourists, both domestic and foreign, flocking to the area.

Shangri-La’s services rival that of industrialized cities of China’s eastern coastal region.

Within the city limits there are three hospitals: one private hospital, one government hospital, and a traditional Tibetan hospital. The private hospital has the capacity to take care of approximately eighty patients, and includes rooms that are private, semi-private, or shared. This particular Shangri-La hospital was constructed in a fashion that would be similar to an American motel, meaning the patients rooms opened into the outdoors rather than a hallway like that of an American hospital. This facility employs the services of ten doctors and fifteen nurses. In fact one, the privately-owned hospital, is the one in which

Dr. Briggs worked two days of the week, when he was not visiting villages making house calls (Briggs).

Dr. Briggs described the particulars of the privately owned hospital facility. This healthcare facility possesses medical equipment including a CT scanner, X-ray machine, and ultrasound machine, the only ones in the Shangri-La area. This hospital also incorporated the use of conventional IV bags in order to administer medication. Although this hospital possesses x-ray machines, CT scanners, and ultrasound machines, these

particular machines are not frequently checked or maintained in dry conditions. Also machines like this are not frequently updated due to their initial high cost so a hospital might use the same piece of equipment until the suggested usury period has long since expired. On an average day Dr. Briggs can see anywhere from 80 to 150 patients. Some of the challenges that Dr. Briggs felt were more prevalent were: sanitation, health education, and communication between doctors and patients. The latter seemed to be a pressing issue because in the past doctors have simply treated patients without informing them about the reasons for their illnesses or potential ways to prevent reoccurrence. This has led to a patient mindset that the doctor should immediately cure any ailments that the patient is suffering from. However, all illnesses are not easily treatable. Dr. Briggs feels that increased doctor-to-patient communication would reduce the amount of confusion and dependency from the patients and allow the doctors operate more effectively

(Briggs).

The Tibetan hospital has the patient capacity of approximately 100 and employs the services of around twenty doctors and ten nurses. The hospital itself is broken up into four separate buildings. The first is a pharmacy building where traditional Tibetan drugs are both manufactured and sold. The next building is a two-story doctor office where family physicians and doctors specializing in internal medicine perform check-ups and treat minor ailments for patients. The third building is a rehabilitation facility where patients can receive acupuncture or electric stimulation to assist patients who suffer from muscle strains or are rehabilitating from surgeries. The final building is where the admitted patient rooms are located. These rooms are slightly larger in size than an

American hospital room but are frequently shared by as many as four patients and their family members at one time (Everett).

Dr. Briggs also arranged for a meeting with a doctor from the traditional Tibetan hospital. This particular doctor had been working at this hospital since she was fifteen years of age when her parents founded this healthcare facility. This medical facility uses traditional Tibetan medications and remedies along with some Western and Chinese medicines. Nearly all of the prescription medication is Tibetan and patients only purchase the medication directly from this facility’s pharmacy. The bulk of the patient load for this individual hospital comes from the surrounding Tibetan farmers who are strong supporters of traditional Tibetan medicine. However, the hospital is not solely dependent on Tibetan treatments. A stimulation machine that sends electric pulses to rehabilitate muscles and joints was been utilized, as well as Chinese acupuncture. Most patients who seek treatment from the Tibetan hospital are agricultural workers from the surrounding villages. Accordingly, most injuries that are treated at this particular facility are orthopedic. Because this particular facility, over time, developed a niche market for treating patients with common orthopedic injuries, citizens perceive this medical establishment as more of an orthopedic clinic rather than an actual hospital (Everett).

Lastly, the government hospital appeared to be the most modern from an outside view. This facility was certainly the largest facility, and it seemed to incorporate conventional Chinese medicine with some Western medical techniques present. This facility would be the one most likely used by tourists unless they became aware of Dr.

Briggs’ presence in the community. This particular hospital receives funding from the

Chinese government and so as to maintain a positive perception of the Shangri-La area to foreign tourists (Everett).

Below in Figure 3, there is a picture of the government hospital that is located in the city of Shangri-La. In comparison it would be about the size of a moderate bank in the United States. On the outside, the hospital resembles that of many metropolitan hospitals of China that would customarily be located on the eastern seaboard. It is common knowledge in the area that the spring and fall months are the busiest for hospitals in the Shangri-La community, because this is when the presence of tourists reaches its peak. The summer months are usually much slower because nearly all of the snow melts off the mountains, except for the highest peaks, and most farmers chose not to visit hospitals because this is the time of year when a majority of the harvest work is being completed, thus, personal health is no longer even a remote priority (Briggs).

Figure 3: Shangri-La Hospital Source: “Shangri-La Hospital”

The Shangri-La community also boasted a pharmaceutical industry that rivals any major Chinese city per capita. Upon surveying the city’s main road, it was discovered that there was a total of approximately twenty pharmacies in the area. In addition to the three hospitals there were private doctors’ offices spread sporadically throughout the city. These particular pharmacies were mostly chain stores with nearly identical signage and pricing. Medicines in most locations were Chinese or Western although some did incorporate more traditional healing methods such as pickled animals, mushrooms, and various roots. In the future, one can expect that as the number of tourists visiting the Shangri-La area continues to increase, the amount and quality of health care infrastructure and personnel will increase accordingly (Everett).

Comparison: Health Care Services

Having discussed the supply of health care services for both Blount County and

Shangri-La, the two can be compared and contrasted. The first similarity is that both

Blount County and Shangri-La have nearly the same bed capacity for patients, approximately 350. The difference is that Blount Memorial has the bed capacity in one facility whereas Shangri-La has a total of three facilities in order to serve its community members. Another similarity is that both locations have health care facilities that are owned by the community. Blount Memorial, as a charter hospital, is owned by Blount

County citizens and likewise the traditional Tibetan hospital was founded by a family of local Tibetan doctors who have since shared ownership with the Tibetan council within the community. Another similarity is that both communities provide different health care services at different locations. For example, Blount County has the Wellness Center,

Occupational Health Center, and Morningview assisted living complex. Shangri-La also,

without aiming to differentiate its health care facilities, has specialized services in each hospital: orthopedic at the Tibetan hospital, short-term care facility in the private hospital, and long-term care in the government hospital (Everett).

On the other hand, there are some apparent differences in the approach the two locations take towards supplying health care services. The first major difference is that in

China, health care services and facilities are rarely advertised. In Shangri-La, three health care facilities competed for members of the community and tourists. However, there appeared to be an absence of media advertising. According to Dr. Briggs, most advertising for healthcare services stems from oral conversation amongst community members. In contrast, Blount Memorial hospital utilizes numerous media outlets in order to market itself to Blount County and surrounding areas including: billboards, television, radio, newspaper, and community awareness programs. Another difference in the two locations is the proximity of competitors. The closest competitor for Blount Memorial would be the few Knoxville area hospitals, but Blount Memorial does not actively market to this particular area due to the existing presence of the other medical facilities. Thus,

Blount Memorial has somewhat of a monopoly on health care in the Blount County region unless residents chose to commute to Knoxville-area hospitals. Shangri-La, however, has three hospitals within a three-mile radius all of which compete for the business of the local citizens (Everett).

CHAPTER III

QUALITY OF CARE

The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease. ~Thomas Edison

The services provided by healthcare facilities are necessary to meet the demands of consumers; however, without quality care, these services do not fully meet the desires of community members. The areas of quality care for emphasis include: health care professionals, facilities, funding, and challenges to providing quality care. These components are needed to render a health care system that can provide quality care. The category of health care professionals will include doctors, nurses, and hospital

administrators. The description of the health care professionals includes an overview of the education requirements and job responsibilities. An analysis of the health care facilities’ infrastructure and medical equipment will ensue. Following the analysis of quality care treatment for Blount Memorial, Shangri-La is analyzed for quality care so that comparisons can be made. Accordingly, similarities and differences between the locations will be discussed.

Blount Memorial Hospital: Quality of Care

Medical professionals are the premier area of focus necessary to provide quality health care to the Blount County community. As common in most hospitals, quality doctors play a key role for making a hospital a quality facility. Blount Memorial’s team of over 165 physicians boasts medical degrees and completion of residency programs from the elite medical schools worldwide. These physicians have earned four-year

Bachelor’s degrees, four-year medical degrees, and completed three years of residency.

In addition, doctors must acquire licenses to practice medicine in the state of Tennessee by the Tennessee State Board of Medical Examiners. They must renew this license every few years to ensure that the physician remains capable of practicing medicine (Blount

Memorial Hospital). Doctors are currently in high demand, especially in the East

Tennessee area, due to the shortage of medical doctors. Thus, salaries can vary according to demand and type of doctor, but have been increasing annually since 1999 (United

States).

Every doctor at Blount Memorial concurs that quality nurses are essential for the effective application of health care services. Most nurses are either registered nurses

(RN’s) or the licensed practical nurses (LPN’s). The main difference between these two types of nurses is the amount of education and job-specific responsibilities. RN’s are required to finish a two to four year educational program whereas LPN’s must only complete a ten-month program. Accordingly, RN’s have more responsibilities than

LPN’s (“Tennessee Health Statistics”). These types of nurses must meet state requirements in order to work in the medical field. Some of these requirements include completing a certified nursing school program as well as a residency period within a hospital. Nurses, similar to physicians, must also acquire certification by the Tennessee

Board of Nursing and renew this certification every few years (Blount Memorial

Hospital). According to national data from the Center for Disease Control, the amount of registered nurses employed nationwide has increased by slightly over 1 percent since

1999, but the hourly wage for registered nurses has increased by over 4 percent since

1999 due to the shortage of nurse’s nationwide (United States). In fact, as Figure 4 predicts below, as the “baby boomer” population continues to enter years of retirement it is estimated that the shortage for full-time registered nurses will be in the excess of one million.

Figure 4: Supply and Demand Projections for Registered Nurses Source: "Health and Hospital Trends"

One method that Blount Memorial has implemented to meet the increasing demands of medical professionals is the tuition assistance program. This program allows hospital employees to continue their medical training or education so that they are able to seek further medical degrees or licensing. As a part of this program, Blount Memorial will provide tuition assistance so that individuals can continue their education.

Recipients of the tuition assistance are accountable for payment to the hospital upon completion of the educational course. This amount is broken into several payments that are due accordingly to a previously established payment period. The tuition assistance program allows employees to seek additional education so as to increase their future earnings, but at the same time the hospital secures the employee for a certain period of time while payments are being made. If an employee does not wish to continue

employment with Blount Memorial, they are expected to repay the tuition assistance amount in full at that point in time (Everett).

Another type of professional that is not commonly thought of, but equally important, is hospital administration. Administrators assume the role of managers of the hospital. These individuals are entrusted with keeping the hospital operating at the highest level of efficiency possible. It is also the responsibility of the administration to ensure that the hospital has quality employees as well as necessary equipment in order to provide the health care demanded by community members. At Blount Memorial, a team of six assistant and associate administrators as well as the head administrator takes on these responsibilities. Most of these professionals have specialized degrees according to their function on the executive team. Such degrees range from focuses in finance to human resource management to clinical management. These niche areas allow the team of administrators to accurately evaluate financial performance, infrastructure, clinical management, information technology, and human resource management (Blount

Memorial Hospital).

Blount Memorial is a firm believer that having competent employees is a vital part of operating a quality health care facility (Blount Memorial Hospital). The percentage the hospital spends on wages and salaries serves as supporting evidence. In

2007, Blount Memorial spent nearly 56.61% of its total operating revenue toward employee wages, salaries, and benefits (Annual Board Report 14).

Figure 5: “Salaries, Wages, and Benefits as % of Total Operating Revenues” Source: Annual Board Report

Figure 5 breaks down the percentages that salaries, wages, and benefits for Blount

Memorial Hospital by month over the 2006-2007 fiscal year. As shown in Figure 5, the amount that Blount Memorial Hospitals spends on employees fluctuates throughout the year between approximately 54% and 57% and is most likely due to structure of the payment scale with regards to necessity of medical personnel (Annual Board Report).

As the largest U.S. industry in 2006, health care provided 14 million jobs: 13.6 million jobs for wage and salary workers and about 438,000 jobs for self-employed and unpaid family workers. Of the 13.6 million wage and salary jobs, 40 percent were in hospitals; another 21 percent were in nursing and residential care facilities; and 16 percent were in offices of physicians. Physicians, dentists, and other health practitioners,

accounted for 295,000 out of the 438,000 total self-employed health care workers

(“Career Guide to Industries: Health Care”). In Table 4, the United States health care employment industry is depicted by employment position.

Employment of wage and salary workers in health care by occupation, 2006 and projected change, 2006-2016.

(Employment in thousands)

Employment, 2006 Percent change, Occupation Number Percent 2006-16

All occupations 13,621 100.0 21.7

Management, business, and financial occupations 579 4.2 18.2

Top executives 98 0.7 11.6

Medical and health services managers 185 1.4 18.6

Professional and related occupations 5,955 43.7 21.3

Counselors 169 1.2 29.3

Social workers 189 1.4 23.3

Social and human service assistants 97 0.7 28.9

Dentists 96 0.7 7.5

Pharmacists 64 0.5 22.2

Physicians and surgeons 468 3.4 17.1

Physician assistants 58 0.4 29.6

Registered nurses 2,072 15.2 25.2

Occupational therapists 66 0.5 28.4

Physical therapists 141 1.0 30.4

Respiratory therapists 91 0.7 23.4

Clinical laboratory technologists and technicians 266 2.0 14.3

Dental hygienists 163 1.2 30.4

Employment of wage and salary workers in health care by occupation, 2006 and projected change, 2006-2016.

(Employment in thousands)

Employment, 2006 Percent change, Occupation Number Percent 2006-16

Cardiovascular technologists and technicians 43 0.3 25.5

Diagnostic medical sonographers 44 0.3 19.2

Radiologic technologists and technicians 184 1.3 15.4

Emergency medical technicians and paramedics 130 1.0 22.3

Pharmacy technicians 60 0.4 31.6

Psychiatric technicians 48 0.4 -5.2

Surgical technologists 82 0.6 24.6

Licensed practical and licensed vocational nurses 605 4.4 13.4

Medical records and health information technicians 142 1.0 18.6

Service occupations 4,334 31.8 27.1

Home health aides 582 4.3 46.9

Nursing aides, orderlies, and attendants 1,240 9.1 18.3

Physical therapist assistants and aides 100 0.7 29.7

Dental assistants 267 2.0 30.3

Medical assistants 390 2.9 36.1

Medical transcriptionists 76 0.6 10.5

Cooks, institution and cafeteria 115 0.8 17.2

Food preparation workers 107 0.8 15.4

Food servers, nonrestaurant 84 0.6 20.0

Building cleaning workers 362 2.7 17.5

Personal and home care aides 307 2.3 53.0

Recreation workers 54 0.4 15.9

Employment of wage and salary workers in health care by occupation, 2006 and projected change, 2006-2016.

(Employment in thousands)

Employment, 2006 Percent change, Occupation Number Percent 2006-16

Office and administrative support occupations 2,446 18.0 14.4

Billing and posting clerks and machine operators 192 1.4 10.2

Bookkeeping, accounting, and auditing clerks 120 0.9 20.9

Interviewers, except eligibility and loan 106 0.8 13.8

Receptionists and information clerks 363 2.7 22.7

Executive secretaries and administrative assistants 130 1.0 20.6

Medical secretaries 380 2.8 17.2

Secretaries, except legal, medical, and executive 190 1.4 6.3

Office clerks, general 335 2.5 21.5 Table 4: Healthcare employment and wages Source: “Career Guide to Industries: Health Care”

Facilities and equipment are the next characteristics that determine the quality of care for Blount County citizens. In order for the staff of Blount Memorial Hospital to operate effectively, the latest technology and machinery must be readily accessible.

Blount Memorial seeks to equip its staff with the most proven medical technology available. This is pleasing to both employees and citizens (Blount Memorial Hospital).

For the purpose of privacy, the monetary amount of property, plant, and equipment is not revealed; it is important, however, to mention that Blount Memorial takes on new additions and renovations to facilities and equipment nearly every year. Also important, the depreciation rate for equipment was less than 50% in 2007, and the equipment generated positive revenues in that year as well. This suggests that Blount Memorial

maintains the value of its equipment through regular inspections and maintenance checks, and by doing so, these assets can generate positive revenues through their use for the hospital. One example of how Blount Memorial is using technology to improve its efficiency is through the implementation of a complete electronic medical care system.

The medical records department has already made the transition to electronic records and medical charting is well under way. Blount Memorial also uses the best available technology in their surgical, radiology, cardiology, laboratory, pharmaceutical, cancer, and birthing centers. One particular piece of equipment that the hospital is particularly proud to own is a machine that robotically finds and distributes over 2,000 prescription drugs that are to be given to patients. This piece of equipment can read request orders and distribute the necessary medication to pharmacists in a matter of moments. By the commitment to equip its staff with the best equipment and facilities available, Blount

Memorial is assuring that the tools are available to administer quality care to the community (Annual Board Report 15).

The expenditures on health care have been growing nationally in the past. The increase in spending is directly related to the desire of both the United States government and its citizens to have the highest quality of health care available. Figure 6 depicts the change in health care expenditures that have occurred between 1980 and 2006. From this data, several inferences can be made. First, the amount spent on national healthcare services and supplies has increased by more than six fold in the last twenty-five years.

The biggest increase in expenditures, by percent, stems from prescription drugs, which more than doubled during this time period from 5.2% to 11.0%, whereas hospital care declined by approximately 10% over the course of the twenty-five year period.

Figure 6: Health Care Expenditures

Source: “Health and Hospital Trends”

The next area of quality care performance is the management of funds. Blount

Memorial Hospital is a non-profit organization. However, this does not mean that it does not collect payment; it simply implies that all excess revenues earned are reinvested into the organization. In 2007, Blount Memorial Hospital’s operating revenues were 5.1% above what was predicted. Blount Memorial is earning more in revenues from operations by administering health care services to the community. Expenses were above budget predictions by 3.3%; thus, the revenues covered the expenses by 1.8%. Non-operating investment income also generated an increase of 128% in revenues. For the 2007 fiscal year, Blount Memorial Hospital gross patient revenue generated 3.7% above the predicted budget, and net patient revenue exceeded budget predictions by 5.7% (Annual

Board Report 14). From this financial data, Blount Memorial appears to have had a

positive financial year in 2007. Based on these statistics the hospital earned more in revenues than it lost in expenditures. Also, patient revenue increased, which possesses multiple interpretations. Such an outcome could mean that more people were injured or sick. However, it could also be interpreted as a positive that more people are seeking health care treatment as precautions, or it could mean that price for services increased.

The likely reasoning for the increase in patient revenue is that a combination of the previously mentioned scenarios took place.

In order to effectively evaluate how well Blount Memorial hospital is managing to uphold the highest quality of care for its patients, national hospital statistics will be compared to those of Blount Memorial to serve as a benchmark for comparison purposes.

It is important to begin with the fact that as of 2007 approximately one-third of all hospitals lose money on operations, thus, it seems justifiable to suggest that Blount

Memorial is operating quite effectively from an aggregate standpoint as a medical facility. As shown in the Figure 7, the percentage of hospitals that possess negative total margins seems to fluctuate in a cyclical pattern. It appears that since 2003, the percentage of hospitals with a negative margin has been on a decrease. However, 2007, not shown on graph, had approximately 33% of hospitals with a negative total margin.

This graph would suggest that because this percent seems to follow a cycle, that the percentage of hospitals would likely increase after 2007 (“Health and Hospital Trends”).

Figure 7: Hospitals with Negative Total Margins Source: “Health and Hospital Trends”

The United States ranks very well in comparison to other countries regarding the amount of expenditures dedicated towards health care. The United States allocates approximately 15.5% of its total GDP towards health care expenditures. This percentage is greater than any of the other 186 countries that were included for this particular statistic. However, the United States ranks 44th on total life expectancy (approximately

78 years) when compared to other nations (“Chinese Health Statistics”).

Blount Memorial’s biggest quality care obstacle is obtaining accurate information about innovations in medical care and internal statistics to guide health care decisions.

With continuous changes and improvements being made in the medical industry, it is

extremely difficult to provide proper care to patients. New technology and procedures require in-depth research to ensure that they will yield desired results. Blount Memorial chooses to stay slightly behind the cutting edge of technology and procedures to make sure that the results are as advertised (Dawson). In order to ensure that Blount Memorial is operating in such a way that meets the expectations of its citizens, the hospital actively seeks accreditation from Joint Commission that is an organization that awards membership for hospitals that are held to the highest of standards. In order to receive accreditation, Blount Memorial was required to submit a lengthy proposal mostly dealing with why Blount Memorial would be a candidate for accreditation and some of its operating procedures. If accreditation is awarded then the hospital is subject to random audits and inspections from the Joint Commission. The main goal of achieving such merit is to communicate the idea that Blount Memorial is actively concerned with the manner in which it operates in regards to public perception. Below in Figure 8 depicts the different criteria that is used to evaluate hospital performance. These requirements are subject to change from year to year; accordingly, Blount Memorial must maintain the ability to adapt to new protocols very quickly (“Hospitals”).

Figure 8: Joint Commission Accreditation Source: “Hospitals”

The Updates The Accreditation Process Sentinel Events National Patient Safety Goals The Joint Commission Quality Report Accreditation Participation Requirements (APRs) Standards, Rationales, Elements of Performance, and Scoring Section 1: Patient‐Focused Functions Ethics, Rights, and Responsibilities (RI) Provision of Care, Treatment, and Services (PC) Medication Management (MM)

Surveillance, Prevention, and Control of Infection (IC)

Section 2: Organization Functions Improving Organization Performance (PI) Leadership (LD) Management of the Environment of Care (EC) Management of Human Resources (HR) Management of Information (IM) Section 3: Structures with Functions

In order to evaluate customer satisfaction on a national level, organizations such as J.D. Power and Associates provide reports that depict consumer attitudes towards health care facilities. According to this organization, patient perception’s of a hospital’s reputation play an important role in hospital selection. The study measures overall patient satisfaction in five categories: dignity and respect; speed and efficiency; comfort; information and communication; and emotional support. Their study, discovered satisfaction rates among recently discharged hospital patients, finds that three-fourths of patients use reputation-related information as their primary criteria in selecting a hospital.

Nearly fifty percent of patients say that the hospital's overall reputation was their primary criterion for selection, while twenty-five percent say the availability of good doctors and having skilled nurses on staff was most important in their selection. As stated in the report, “Perception plays an important role in the choices today's healthcare consumers make,” said Steven D. Wood, senior vice president and general manager of the healthcare practice at J.D. Power and Associates.

More than ever before, patients have a choice for their healthcare providers, and

this choice depends a great deal on the personal services rendered at a highly

emotional time in their lives. As patient choices increase, hospitals need to

continue to enhance the clinical and experiential quality of patient care and

effectively communicate their performance in the communities they serve.

(“Reputation”)

The study found that fifty-nine percent of the individuals whose hospital stay was planned indicate that they were involved in the hospital selection decision either independently or with a doctor. However, only 8 percent felt they were constrained by what their health care plan would allow. Patients who were "delighted" with their hospital experience (providing a score of 10 on a 10-point scale), accounted for a strong majority, eighty-six percent. These individuals confirm that they are likely to choose the same hospital in the future should the need arise, and eighty-three percent would recommend the hospital to others (“Reputation”).

Both the Joint Commission and the national J.D. Power and Associates performance standards are benchmarks that Blount Memorial uses to evaluate its performance in regards to customer satisfaction. These organizations provide a means for Blount Memorial to gain the information of consumer opinions because in the world of health care perception is reality.

Shangri-La: Quality of Care

Describing the quality of care in Shangri-La is difficult because of the uncertainty that comes from the differences in cultural perspective. Whereas in the United States citizens have certain expectations on the manner in which a quality health care facility should be operated, citizens in China, especially rural citizens, have a completely different set of core values that dictate their judgment about the quality level of the medical facility and its personnel. It is vital that these differences in culture are taken

into consideration while comparing and contrasting the two different locations and the way in which each operate.

To begin with, Chinese medical professionals are held to different education requirements than those here in the United States. Upon completion of secondary school,

American high school, Chinese students are given a standardized entrance exam to determine their eligibility into a college/university. If a student earns the required score on this entrance exam, they are then accepted into a university. At this point the student chooses their specific area of focus much like an American student would select a major area of study. Students wishing to become doctors would choose a science-related focus area and upon completion of a four-year program would then have the ability to pass a national medical examination that allows them to become a licensed doctor. If the student wishes, they may continue their education and earn a master’s degree in medicine with which they would be a lead doctor and enjoy higher salaries and shift priority at hospitals. If desired, they can earn a doctorate in medicine can be achieved with an additional two years of education, and at this point the individual would likely find employment at the elite hospitals throughout the country and work as the medical chief of staff at most locations (Briggs).

However, most rural areas in China do not have the luxury of employing such highly trained individuals. Most remote villages employ “village doctors,” who in most cases have completed a brief training course and can meet only the minimal medical demands of the citizens. In most cases this individual would take on the responsibilities of administering school vaccinations for children, prescribing over-the-counter

medication for minor aches and pains, or consult the nearest medical doctor to make the appropriate decision regarding the health of the individual (Briggs).

Nurses are another medical profession that differs greatly in China when compared to the United States. Nursing training would be comparable to that of LPN training in the United States. The length of the training program depends on the skill level and desire of the individual. Upon completion of secondary school, nurses with more education seek the higher salary positions and accept the increased patient responsibilities. These responsibilities are medically similar to those of an American RN as far as patient care is concerned (Briggs). However, the biggest difference in China is that there does not seem to be as quite as a personal relationship between nurse and patient. Usually, the only time a nurse will visit a patient’s room is to administer some form of medication. Another difference of Chinese patient care is that families are responsible for all food services for sick family members while in the hospital. There is no cafeteria or nutritionist available to oversee the diet of patients. This seems quite foreign to what has become customary in the United States, but the main benefit for

Chinese hospitals is that all food costs are eliminated (Everett).

The next area that is a crucial part of the quality care strategy is equipment and facilities. Shangri-La is one of the best-equipped non-metropolitan areas in all of China.

It is quite rare for a city of its population size to possess some of the medical equipment that is available for use. This is likely due to Shangri-La being one of the biggest tourist attractions in western China. Nevertheless, Shangri-La has in its possession much of the same medical equipment that is present in Blount County (Everett). However, the main difference is that while Shangri-La possesses such amenities as a CT machine, x-ray

machine, and ultrasound machine, this equipment is rarely checked or evaluated for effective usage. Another negative aspect to such modern equipment is that frequently doctors are inexperienced in the recommended ways to operate such machinery. For example, the CT machine, which is commonly used to take pictures of the brain, also has the ability to take a chest cavity photo. However, “many doctors are not adequately trained on how to interpret a chest CT reading and consequently blame the machinery for faulty use” (Briggs).

The qualities of medical facilities are another point that differs significantly from those of American facilities. Whereas in America, such facilities are regulated by such safety standards implemented by organizations such as Occupational Safety and Health

Administration (OSHA), Chinese facilities apparently must only meet minimal national safety standards. With the exception of the government hospital, both the private and the

Tibetan hospital were constructed in such a fashion that would be typical of an American motel. Patient rooms opened into balconies that were not enclosed and usually in the form of a horseshoe with an open courtyard filling the middle open space. It was suggested that this construction helped minimize operational costs by lowering electric and other utility expenses. At the same time, this approach has the potential to cause numerous health concerns such as slippery pavement, abundance of airflow, and the lack of insulation would make winters in a Shangri-La hospital frigid at best (Everett).

Lastly, the manner in which Shangri-La manages its finances will be discussed.

This is one particular area that proved to be quite difficult to research. However, some general inferences can be made solely from observation and casual conversation. Having consulted with residents from Shangri-La, most residents feel that the funding for their

health care facilities are fairly adequate, but at the same time, a majority would agree that more could be done to improve the health care system in the community. Citizens would like to see the government allocate more funding towards the support of health care practices (Briggs). This desire seems justified when observing China’s total health care expenditures as a percent of their overall Gross Domestic Product (GDP). China spends less than five percent of its GDP on health care which earns them a poor ranking when compared to one hundred and eighty-seven other countries worldwide; nearly three percent of this funding is from the private rather than the public sources. Although China has not been allocating significant financial resources towards health care directly, it is spending the most amounts, over eight hundred million dollars, on water sanitation improvement projects. However, China ranks 102nd out of 220 countries worldwide in total life expectancy (approximately 73 years) (“Chinese Health Statistics”).

Comparison: Quality of Care

Even though expectations of quality health care are different between Blount

County and Shangri-La, some similarities can be found. For instance, both systems employ trained health care professionals. Both locations employ medical personnel that have acquired the appropriate training and educational requirements. Another similarity between Blount County and Shangri-La is that both health care facilities can adequately accommodate the needs of community members. This is quite different than health care systems in urban areas, both in the United States and China, who frequently have excessive waiting times because there are simply too many of patients. Other similarities

include common medical equipment that is frequently used, such as CT scanners, X-ray machines, and ultrasound (Everett).

The differences in the quality of care between Blount County and Shangri-La seem to outnumber the similarities. For example, the amount of education that is required for medical personnel is substantially different in Blount County than that of

Shangri-La. Doctors in Blount County must obtain a degree from an accredited medical school and complete a residency program within a hospital upon the completion of an undergraduate degree. This process can range from five to ten years after an undergraduate degree has been obtained. In contrast, Chinese doctors may only complete an undergraduate program in order to practice medicine. Nursing education requirements is another aspect that differs between the two locations. Nurses in the United States are held to more stringent education requirements than nurses in China, but by acquiring a more extensive degree/title, American nurses must undertake additional responsibilities.

The maintenance of medical equipment is another point of differentiation. According to

OSHA regulations, medical equipment at Blount Memorial must be evaluated every so often in order to insure the equipment is functioning properly. Shangri-La, on the other hand, possessed no visible evidence that machinery had been evaluated (Everett).

The expenditures of health care as an overall percent of Gross Domestic Product

(GDP) provides another means of both comparison and contrast for the Blount Memorial and Shangri-La. As of 2004, China spent 4.7% of its total GDP towards health care expenditures. From this 4.7%, 2.9% was contributed privately (individuals) while the public (government) spent the additional 1.8%. This particular report sampled a total of

187 countries, and China ranked 134th in terms of expenditures as percent of total GDP.

Furthermore, China ranked 149th out of 187 countries in terms of governmental expenditures towards health care, while the private sector’s expenditures earned a ranking of 58th (“Chinese Health Statistics”). In comparison, the United States spent 15.4% of its total GDP on health care expenditures, ranking them first amongst all included nations.

The United States also had the highest percent of private expenditures devoted towards health care at 8.5% of total GDP. The government allocated 6.9% of its total GDP towards health care expenditures, a ranking of 21st out of the surveyed 187 countries

(“United States Health Statistics”). These expenditure percentages suggest that while the

United States is heavily focused on health care, American citizens are expected to endure the bulk of these expenditures. Conversely, Chinese health care is not as significant as a priority to both its people and government, or as a newly industrializing country, China struggles to produce funds to provide healthcare. These statistics also suggest the similarity that both the Chinese and American governments believe that the responsibility of health care is assumed by the individual citizens rather than the government.

CHAPTER IV

ACCESSIBILITY TO HEALTH CARE SERVICES

A common misconception is that the costs of health care are cheaper in rural America; when in fact, the reality is that they are more expensive and more difficult to access Blanche Lincoln

The final issue that is examined to effectively evaluate the overall performance of the health care system is the accessibility to the health care services. Even if a health care institution meets the demands of consumers and provides a high quality of care from its employees and resources, the services must be accessible to community members in order for the health care system to be truly effective. Accessibility is determined by the amount of time patients must wait to receive access to health care treatment as well as the affordability of the services to the consumers. In order to analyze the accessibility of health care facilities, the travel time and waiting time for care will be discussed. The affordability will be determined by viewing data on community members that are insured, uninsured, along with the different payment options available. Then, a comparison will reveal the similarities and differences between Blount County and

Shangri-La.

Blount County: Health Care Accessibility

One of the most difficult tasks that Blount Memorial is continuously faced with is improving the accessibility of quality health care services to consumers in the most time- efficient manner. One way to evaluate time efficiency is to determine the average time of arrival for individuals at this health care facility, and the time that individuals wait to see medical professionals in the waiting room. Blount Memorial’s main regional territory focuses on Blount, Sevier, Monroe, and Loudon counties, but individuals from other nearby locations frequently seek the services that Blount Memorial has to offer. Blount

Memorial’s territory is so vast it is difficult to calculate an average time that it takes

patients to reach the Blount Memorial facility. Arrival times range from a matter of minutes up to an hour depending on the starting location of the patient. Fortunately, both the Rural Metro ambulance service and the Lifestar helicopter services decrease arrival times significantly (Blount Memorial Hospital).

Blount Memorial is currently a class three-trauma center meaning it does not employ cardiovascular surgeons or neurosurgeons. However, Blount Memorial can stabilize a patient’s condition until the individual can be transported to facilities that perform such services (Blount Memorial Hospital). Once patients arrive at Blount

Memorial, it is vital to ensure that they are seen by the appropriate medical professional as soon as possible. Blount Memorial has incorporated a technologically-advanced, emergency department that utilizes the abilities of computer record systems to decrease the average waiting time for patients. Waiting times for patients are recorded monthly and tabulated for yearly reports. The average time patients wait once having entered the door until they were seen in the treatment area was 32 minutes. The average time patients wait for examination and discharge was 3 hours and 29 minutes. The average time it took patients to move from treatment area one to provider one was 41 minutes, and the time it took for a patient to walk in the doors and register was one minute. These waiting times have all been decreasing on average over the last five years due to the technological advances and the staff being able to effectively implement such technology.

Table 5 is a report that lists in detail the various waiting times for patients at Blount

Memorial Hospital in March of 2008 (“Emergency Department Statistical Report 1”).

Table 5: Emergency Department Statistical Report Source: “Emergency Department Blount Memorial Hospital”

In general, travel times to the Blount Memorial Medical facility has been decreased by strategically placing “satellite facilities” throughout the service area.

Individuals living in the surrounding communities may enjoy quicker travel times to external facilities without having to commute to the main Blount Memorial campus.

However, services that these satellite facilities provide are somewhat limited due to low amounts of activity. Still, the travel times are reduced in some cases from over an hour drive to less than fifteen minutes (Dawson).

The affordability of health care services is the other determinant of accessibility.

If members of the community are unable to afford health care services, then all efforts made by the health care institution to meet the demands of consumers, provide quality services, and administer these services in a timely manner are wasted in the end. It is no secret that the rising cost of health care is a major issue in the United States. In 1998, nearly three-quarters of a million Tennesseans were uninsured. By 2006, that number would increase to over 780,000 citizens, ranking 16th worst among all fifty states

(Community Health Status Report 11). In the United States, around 84.7% of citizens have some form of health insurance; either through their employer (59.3%), purchased individually (8.9%), or provided by government programs (27.8%). Some of these individuals obtain coverage from multiple payment options which accounts for the overlap. Certain publicly-funded health care programs help to provide for the elderly, disabled, children, veterans, and the poor, and federal law mandates public access to emergency services regardless of ability to pay. The U.S. government programs accounted for over 45% of health care expenditures, making the U.S. government the largest insurer in the nation. The per capita spending on health care by the U.S. government placed it among the top ten highest spenders among United Nations member countries in 2004. Americans without health insurance coverage at some time during

2007 totaled about 15.3% of the population, or 45.7 million people (“Health Insurance

Coverage: 2007”).

Based on statistical data, Blount Memorial has broken down methods for payments into the following categories. This pie chart depicts percentages that are based on the 12,038 discharges that were made by Blount Memorial in 2007 and are depicted in

Figure 9. According to the methods of payment, it appears as though the most of Blount

Memorial’s patients are elderly and makes payment through Medicare and

Medicare/HMO’s. The next category, private insurance, includes individuals who have insurance from employers or pay personally for their insurance coverage. Another category includes self-pay where the individual is financially responsible for all medical costs. TennCare is the other state-payment plan (Annual Board Report 11).

Figure 9: “Discharges BMH 2007” Source: Annual Board Report

The Center for Disease Control and Prevention collected information on the number of users in the Medicare program as well as the annual Medicare costs since

1970. Blount Memorial’s high number of Medicare patients coincides with these national statistics. Since 1970, the number of Medicare users has more than doubled from around 20 million to currently over 43 million participants. Over this same period of time, the total Medicare expenditures have grown astronomically from $7.5 billion dollars in 1970 to over $408 billion dollars in 2006. Other problems associated with the

current Medicare system include the following. First, Medicare only pays 91 cents for every dollar spent on Medicare patients. Second, the shortfall of Medicare funding for hospital care exceeds 18 billion dollars. Because Medicare does not adequately compensate hospitals the hospitals are then forced to increase care costs for other patients to reconcile the loss, also known as cost-shifting (“Health and Hospital Trends”).

From this information on health care accessibility, it appears the biggest problem stems from the affordability issue. One reason that health care costs have increased in

Blount County is due to doctors wanting to increase their own profitability. By performing certain procedures in office, doctors can choose which patients to treat.

However, Blount Memorial does not possess the same luxury and is required to treat anyone that enters the doors. This results in a higher number of people coming to the emergency room with ailments that would typically be treated by their primary care physician. It is predicted in the future that the hospital is likely to employ more primary care physicians as hospital employees to reduce emergency room overcrowding

(Dawson). With health care insurance costs continuously increasing, individuals are forced to lower their coverage levels. Sadly, in worst-case scenarios individuals with serious health problems are unable to afford treatment. However, the hospital is obligated to treat to the best of their ability and must shift these costs by raising prices for certain individuals (Everett).

According to a report on the state of Tennessee performed by the Center for

Disease Control and Prevention, Tennessee ranks third nationwide regarding health care inaccessibility due to increasing costs. In 1997, the percentage of individuals who could not receive medical care because they were unable to afford the costs has risen in

Tennessee from 4.6% to 7.0%. Since this time, this percentage has grown to nearly 9%, seventh worst among states. The percentage of people who could not afford prescription drugs has increased from 8% in 1997 to over 11% in 2005. This percent was third worst among all states. This data serves as evidence that the state of Tennessee has room for tremendous improvements in regards to making health care more affordable to its citizens

(United States).

Shangri-La: Health Care Accessibility

The accessibility of Shangri-La’s citizens to healthcare services is one that remains quite unique when compared to most typical rural Chinese communities.

Accessibility will be determined as before when evaluating Blount County, in terms of travel-time and affordability.

In regards to the amount of time it takes residents to receive medical treatment,

Shangri-La area residents enjoy that a healthcare facility is a mere minutes away in most cases. Some residents who live in the surrounding villages may be challenged with commutes around thirty to forty-five minutes, but for the most part the largest part of the population is within the ten to fifteen-minute or less range. This is made possible through an efficient transportation infrastructure where paved roads are a norm and traffic is moderate at worst. In comparison, citizens in other Chinese areas can endure travel times exceeding four hours to the nearest hospitals, but this particular travel time is for the most remote villages that usually have poor transportation infrastructure in place. It is because

Shangri-La is such a tourist attraction that the government has equipped this community with sufficient funding and infrastructure to meet the health care demands of both its residents and visitors. These luxuries are likely to increase in the future in efforts to

boast future tourism levels; the Chinese government has allocated more than adequate resources to support this community (Everett).

Once a patient reaches the hospital, it becomes more of a struggle to receive prompt treatment. In China, treatment priority is given to those with the most severe ailments. Thus, individuals with injuries that are not fatal often are attached with numerous hours of waiting before being seen by the medical staff (Briggs).

The affordability of healthcare services in Shangri-La seems to be an issue that is continuously improving in the community, but can stand much more improvement. Due to the payment structure of Chinese medical expenses, many rural Tibetan families lack the ability afford multiple medical treatments (Everett).

As Dr. Briggs explained, many families, because no insurance or alternative methods of payment are in place, are forced with the decision of treating a younger member of the family and older member of the family. Sadly, in most cases, families must take on huge amounts of debt to treat both cases. Usually, such a scenario would render a selection to treat the younger member of the family while choosing to not treat the elderly member of the family. This scenario has been due to a relatively recent change in the Chinese healthcare system (Briggs).

Until 1979, Chinese citizens had enjoyed the benefits of a free healthcare system, but when the Chinese government made the decision to switch to a privately-operated health care system, the citizens suddenly found themselves unable to afford health care treatment. Over the last thirty years, citizens have paid much of their healthcare, always frugally saving any excess income so that if a medical emergency did present itself, it would not completely devastate the family’s finances. Currently on the east coast many

large corporations are beginning to provide health insurance to employees, but this has been a trend unknown to the citizens of rural western China. Currently, about 83% of rural citizens pay for medical costs out-of-pocket. In some communities efforts have been made to start a group insurance plan among farmers where families pay into a pool fund to cover medical costs. Unfortunately, this approach tends to dissolve with the onset of the first drought or poor harvest season. This has been the case for many Tibetan families in the area, but there are some doctors who are attempting to make a difference.

Dr. Briggs treats his patients free of charge so that the fear of high medical costs is not an issue. However, all doctors do not have the luxury of being funded by charitable organizations like Dr. Briggs. Thus, doctors are being urged to help in the education of patients to make them aware of prevention techniques that could significantly decrease the chance of illness. More economical medications are also being recommended more frequently which hopefully can replace previously high cost drugs. If implemented effectively, this could increase the affordability of healthcare services to the Shangri-La community (Briggs).

Comparison: Health Care Accessibility

Now that the accessibility of healthcare has been discussed for Shangri-La, the similarities and differences will be revealed between the locations of Shangri-La and

Blount County. One similarity of health care accessibility between the two locations is both have a significantly wide range of travel time to a medical facility. In both Blount

County and Shangri-La, travel times for reaching an emergency medical facility can range from a matter of minutes to in excess of an hour. One reason for this wide variation of travel time is due to the unique geographical features that both communities

possess. Both are located on the foothills of mountainous regions, thus making some travel difficult, especially in unfavorable conditions such as ice, rain, and snow. It seems that the main advantage that Blount County possesses over Shangri-La is the use of helicopter support or Lifestar, as it is known in Blount County. This means of transportation can greatly minimize the travel time for emergency cases, such as car accidents and outdoor recreational accidents (Everett).

The main difference regarding accessible healthcare is definitely affordability.

Even though 7% of Tennesseans are unable to afford some medical services, there are support systems available, such as Good Samaritan Clinic that provides health care to low-income families. In contrast, there is no such system available in Shangri-La.

Unless Dr. Briggs’ services are counted, citizens who are unable to afford health care services in Shangri-La simply are forced to survive without. There is no system such as

Medicare or Tenncare, which at least covers most of the cost for the elderly and youth populations. Yet another difference in the two health care systems is that most citizens in

Blount County are covered by employer insurance whereas very few Shangri-La citizens have such coverage (Everett).

CHAPTER V

FINAL THOUGHTS REGARDING HEALTH CARE ANALYSIS

“To preserve health is a moral and religious duty, for health is the basis of all social virtues. We can no longer be useful when we are not well.” -Samuel Johnson

The main purpose of conducting an in-depth research about the health care facilities in the United States and China was to discover if it would be possible to draw conclusions regarding the demand for health care services, the supply of health care services, the quality of care, and the accessibility to health care. From these deductions, one would also hope to obtain the ability to provide suggestions that could potentially improve existing health care systems. Accordingly, this section will review findings about the demand of health care, then the supply of health care services, followed by the quality of health care, and finally, the accessibility to health care in Blount County and

Shangri-La with the goal to see what lessons they can provide to improve the provision of health care by health care facilities.

In order to ensure that a thorough analysis of the health care for the communities of Blount County and Shangri-La is achieved, some of the terminology that is included in this chapter will be defined in a similar fashion to those that were previously defined in

Chapter I. Included in Table 6 are the definitions for terms that will be used for the final analysis on the health care of Blount County and Shangri-La.

DEFINITION Asymmetric Information Situation in which one party has more information than another party Moral Hazard Risk that a party has not acted in good faith or has been deceptive Adverse Selection Target group is chosen over another based on favorable characteristics

Table 6: Definition of Economic Terms Source: “Economic Terms Dictionary”

It is necessary to first discuss the cultural differences regarding health care expectations. The health care that is provided in the United States is held to a completely different standard than those of China. The different cultural perception of health care is why the expectations differ so greatly. The point of this explanation is to allude to some

of the ensuing proposed solutions that will be made. It is necessary to keep aware that the recommendations are made from the perspective of an American citizen whose expectations and perceptions are those in accordance of such an individual (Everett).

In addition to possessing different cultural expectations of health care, both the

Blount County community and Shangri-La have illnesses that are culturally specific to each respective region. In Shangri-La, tuberculosis is an illness that is quite common due to cultural norms that are prevalent in Tibetan culture. It is customary to spit in Shangri-

La if the individual experiences any congestion. This is the cultural norm for Tibetan citizens in the area; consequently, the act of frequent spitting is the driving factor that increases the occurrences of tuberculosis in the community (Briggs).

Blount County also possesses cultural norms that increase the rate of area-specific illnesses. Obesity is an illness that impacts Blount Countians because this community is rich in “Southern Style” cooking which popularizes deep-frying foods into fatty oil substances that are high in sodium content. This culturally-based cooking style, along with the fast-food industry, which is ever popular in Blount County, plays a crucial role in deteriorating the nutritional intake of the community members. The decline in nutritional intake stemming from poor dietary eating habits is the major contributor for the high frequency of obesity cases in the Blount County community.

Demand for Health Care Services

Over the course of history, injuries and ailments have undergone countless changes in form. The ailments and injuries that devastated the Roman Empire are no longer present because humans made appropriate adaptations in health care practices and eliminated these health defects over time. Modern times are no exception; the day will

come where cancer will be treatable and will no longer claim the lives of millions annually. Consequently, history has also shown us that there are always new obstacles that pose health concerns to humans. The ensuing information will suggest potential solutions that would minimize the negative effects that are associated with many injuries and illnesses that are common to citizens of Blount County and Shangri-La.

Injuries

To begin, solutions that could alleviate some of the common injuries of both population face is discussed. The first problem deals with the injuries that are associated with heavy lifting. Because both areas have high occurrences of back-related injuries, usually linked to strenuous lifting, appropriate preventative measures may reduce the frequency of back-related injuries. One solution may be to provide educational information on proper lifting techniques so as to minimize the stress that is placed on the body. In many cases, poor habits are developed because individuals have not been adequately trained on the appropriate fashion needed to execute certain tasks. By instructing individuals on the proper way to lift objects, especially those over twenty pounds, the high rates of back injuries could decrease. The government, local health care provider, and local medical professionals have the ability to act as a cohesive unit so that their efforts educate the community members on the appropriate means to lift or carry heavy materials.

Working around sharp objects, mostly in agricultural and industrial settings, is another area where injuries frequently occur. Those who are going to be around such objects should pay extra attention while operating around sharp objects. In addition, protective wear may be an alternative option so as to reduce the likelihood of lacerations

while on the job. Another solution to decrease the frequency of flesh wounds might be to decrease the overall amount of time an individual is around such objects. Employers, by attempting to keep those who are most cognizant around potentially dangerous objects, minimize the chance that fatigued individuals are injured while at work.

Illnesses

Necessary precautionary procedures can also prevent frequent illnesses. This is one particular area in which citizens of Blount County can learn from those of Shangri-La and vice versa. For example, for years smoking has been a major health concern for residents of Blount County. Since 1964, the United States placed warning labels on cigarettes, these individuals and other American citizens became informed of the dangerous effects that are directly related to smoking. These warnings were required to be present on all tobacco products including the following Surgeon General’s warnings:

SURGEON GENERAL'S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, And May Complicate Pregnancy.

SURGEON GENERAL'S WARNING: Quitting Smoking Now Greatly Reduces Serious Risks to Your Health.

SURGEON GENERAL'S WARNING: Smoking By Pregnant Women May Result in Fetal Injury, Premature Birth, And Low Birth Weight.

SURGEON GENERAL'S WARNING: Cigarette Smoke Contains Carbon Monoxide.

(“Surgeon General’s Warning”)

In a further effort to reduce smoking in the United States, community awareness projects provided information to its citizens about the negative impacts that are associated with smoking. In Shangri-La, smoking is becoming increasingly popular; however, the

negative health impacts are not as well advertised. It would be to the benefit of the

Shangri-La community if it would discourage smoking by educating its citizens of the detrimental effects that smoking can have on one’s health.

Shangri-La can also improve health conditions by increasing sanitation efforts.

For example, sanitation is viewed in two completely different manners. In the United

States, hospitals are expected to be an extremely clean environment. If American citizens do not perceive a hospital as having appropriate sanitation, then individuals will simply choose not to use the services of that particular hospital. The unsanitary hospital then changes to meet the expectations of patients. In contrast, Chinese citizens do not possess the same expectations for sanitation; thus, hospitals do not strive to exceed the expectations of Chinese citizens. Therefore, it is unlikely that a Chinese citizen perceives the hospital as unsanitary and no changes will be made.

Shangri-La citizens can also show Blount County residents ways to improve their health issues regarding weight problems. The citizens of Shangri-La have been able to maintain physically-fit bodies in terms of weight management through various means.

Shangri-La citizens take full advantage of the mountainous regions that surround the community. It is quite common for citizens to venture into the nearby Himalayans at least once a day for if nothing more than recreational enjoyment. The citizens of Blount

County have the ability to enjoy similar outdoor activities if the Smoky Mountains and the Greenway trails are adequately utilized. Also, Shangri-La citizens express their cultural heritage by holding nightly dances in the town square. These dances provide a means for both young and old citizens to come together and celebrate a common enjoyment that is traditional Tibetan dancing. Unlike many individuals in Blount

County, the Shangri-La citizens also possess a sense of self-discipline in regards to eating habits. They simply eat no more than they need to in order to suffice their bodies’ needs.

Although excess food is available, a diet of around 1800-2200 Calories would be common for Shangri-La citizens (Everett).

Supply of Health Care Services

Internal

The health care services that are provided by both health care facilities internally may witness improvement if certain alterations and additions are incorporated. In many cases patients are unaware of some of the hospitals’ resources that are available for patient use. One thing that hospitals of both Blount County and Shangri-La could do so as to increase internal preventative health care may be to formulate an on-site educational program so that patients are informed on the multiple services that are provided within the main hospital facility. For example, they could provide daily presentations that outline the services that the particular facility supplies. This would address some asymmetric information regarding knowledge of services. By providing this information, individuals of both Blount County and Shangri-La, would gain awareness of the appropriate actions in dealing with specific health issues. Blount Memorial may also be able to utilize local resources for its benefit. For example, by utilizing the services of

Maryville College, Blount Memorial could form a partnership with this academic institution in conducting medical research that has the potential to assist with community health education through such outlets as the Center for Strong Community located at

Maryville College. Throughout the United States, much research is performed on college campuses, by incorporating Maryville College into community health efforts, Blount

Memorial could perform research and development testing in close proximity to the main health care facility.

One issue that citizens of Shangri-La may benefit from the example of Blount

County citizens is the hospital’s incorporation of service-specific areas throughout the facility. Patients in Shangri-La do experience some overcrowding and long waits upon arrival due to the confusion of patients because they are unaware of where in the medical facility they should report for service. If separate areas of the medical facility were dedicated to providing care for these particular individuals, then the waiting times and overcrowding of patients would likely decline. Evidence for this is shown in Blount

Memorial through the numerous sections and areas that are dedicated for specific areas of care that reduces overcrowding for the respective areas.

External

Health care facilities may also implement certain improvements so as to address the external services problematic areas. The citizens of Shangri-La could potentially benefit from such services that are provided by home health at Blount Memorial. A home health program would allow medical personnel to travel to individuals’ homes rather than the individuals making continuous hospital visits. By decreasing the number of people visiting the hospital, a reduction of waiting times and the volume of patients present at the medical facility would occur. A home health program would also aid those who may not be able to make the commute to the closest medical facility. Although some doctors in Shangri-La do make house calls, their visits are infrequent and usually under unique circumstances.

Citizens of Shangri-La may also benefit from such external services as the occupational health programs which are incorporated in the Blount County area.

Although there is not a large industrial or manufacturing presence in Shangri-La, the service industries possess unique health problems. Shangri-La possesses many shops and restaurants in which open flames and heavy lifting is common. Preventative health practices could take place if funding from government enables the Shangri-La hospitals to institute an occupational health program to target work-related injuries. Training from the occupational health personnel could reduce the occurrences of such health concerns.

This would also serve to minimize the amount of citizens that are coming into the

Shangri-La hospitals due to work-related injuries.

Shangri-La would also likely benefit from the use of emergency helicopter services so that individuals who are in remote locations could have a fast-response means of transportation to a medical facility. Although the initial costs for such a piece of equipment may be high, the long-term revenues that could be generated, not to mention the lives that could potentially be saved, greatly outweigh these initial costs. Currently,

Blount Memorial subcontracts the services of Lifestar so as to provide a means of fast- response to those who are in remote locations.

Quality of Care

Medical Personnel

Many would argue that the medical personnel is the most essential component of the health care facility in regards to providing a high quality of care for patients.

Providers in Shangri-La may improve their quality of medical staff by increasing the accessibility of medical schools for individuals pursuing medical careers. This may

reduce the volume of patients that doctors are barraged with on a daily basis. Also, tuition assistance has the potential to open the door of a medical career to those individuals who have the characteristics of a good doctor but simply lack the financial means. As described in Chapter III, Blount Memorial has started a tuition assistance program to those pursuing medical education. This program appears to be successful in that the hospital secures employees for a particular amount of time, and individuals are able to continue their education so as to earn higher wages in the future.

One way that Blount Memorial might benefit is to encourage medical staff to devote some of their time towards serving the less fortunate members of the community.

In Shangri-La, it is common for some doctors to see as many as 100 patients in a single day. While the thoroughness of each examination may be less, Shangri-La doctors seem to have a heightened sense of community responsibility that surpasses that of many

Blount County physicians. It seems as though medical personnel in Blount County, as well as other locations in the United States, have allowed themselves to become complacent in terms of providing health care. By providing treatment to the underserved, medical personnel may be able to increase their personal sense of responsibility towards the community.

Another option that has the potential to benefit Blount Memorial Hospital would be to further incorporate the services of Maryville College in dealing with the issue of health services research. Health services research is:

The integration of epidemiologic, sociological, economic, and other analytic

sciences in the study of health services. Health services research is usually

concerned with relationships between need, demand, supply, use, and outcome of

health services. The aim of the research is evaluation, particularly in terms of

structure, process, output, and outcome. (“Glossary”)

Blount Memorial has the ability to utilize the untapped resource that is the Maryville

College student body. This nearby college campus has the ability to conduct studies that would include the specific target areas that are a part of health service research. This means of research could also be highly economically-efficient in terms of costs for

Blount Memorial Hospital.

The city of Shangri-La can potentially benefit from the services of a medical administration staff. Shangri-La hospitals possessed no administration council and by employing these particular medical professionals, the hospitals could more effectively reach the goals set by health economics. Health economics is defined as

The study of how scarce resources are allocated among alternative uses for the

care of sickness and the promotion, maintenance and improvement of health,

including the study of how healthcare and health-related services, their

costs/benefits, and health itself are distributed among individuals and groups in

society. (“Glossary”)

By including the expertise of medical administrators, Shangri-La hospitals would allow clinic professionals to focus their efforts on providing care for patients rather than keeping up with financial and organizational concerns. It seems as though this would improve the quality of health care that these clinical professionals are able to provide.

It is difficult to make drastic changes regarding medical equipment due to the high costs that are associated with such machinery. To suggest that Shangri-La hospitals should simply purchase new equipment would be quite naïve and a very unlikely

solution. However, these hospitals could improve the status of existing products by administering regular equipment checks to ensure that machinery continues to operate properly. Improving the conditions that the medical equipment is stored has the potential to prolong the equipment lifespan. Most of the expensive machinery, CT Scanners and

X-ray machines, are stored in areas with poor surrounding construction. Instead of placing machinery on the outer extremities of the medical complex, the hospital might place the machines in the interior areas of the medical facility. This would minimize the weather exposures that are more severe on the outer areas of the infrastructure.

Facility

Health care facilities in Shangri-La provide an interesting method of lowering costs that are necessary to operate all of the area’s hospitals. Instead of having a large facility that is completely enclosed, the hospitals are usually exposed to the outdoor elements. This is one way that the Shangri-La hospital has managed to keep expenditures low; however, this construction method also poses numerous threats to patients’ safety.

During poor weather conditions, floor surfaces become hazardous to individuals moving throughout the facility. By spending more initially on infrastructure that will cater towards safety rather than cost efficiency, Shangri-La hospitals would be able to ensure patient safety while at the hospital and decrease the chance of accidents.

Blount Memorial’s medical facility is forced by law to adhere to the regulations passed down from OSHA; accordingly, the required inspections ensure that Blount

Memorial is operating in a safe manner throughout the year. However, these inspections are frequently common knowledge prior to the inspection. It may be effective to

administer random inspections by an unbiased group so as to ensure that safety is not simply maintained on inspection days.

Accessibility

Travel-Time

As previously mentioned, individuals must possess the ability to receive medical care in a prompt fashion or the efforts of the health care system are not reaching full potential. Both Shangri-La and Blount Memorial are confronted with the difficult task of overcoming geographical obstacles to make health care services time-efficient to access.

It would seem that this is a continuing struggle for both health care facilities, but there may be some solutions that would decrease travel time even more. To begin, all four medical facilities are accessible from major roadways that allow for efficient commute for individuals. However, having the main entrance come via a major roadway has negative impacts as well. In times of high traffic, these major roadways may become increasingly congested with other vehicles/pedestrians. Thus, alternate entryways would be beneficial to these facilities. Although Blount Memorial does have multiple entry points, the emergency entrance faces the major roadway. Thus, even though the ambulance has the ability to enter from multiple sides, an ambulance must navigate through the parking lot around the facility if the back or side entrances were taken. This may lead to potential admittance problems.

Affordability

The affordability of health care is the one area in which both Blount County and

Shangri-La can achieve the most improvement. This observation is not surprising

because it seems that affordability is the key to being able to provide the highest level of health care for communities.

In Blount County, affordability poses a problem to individuals because too often insurance programs do not provide insurance for all citizens. Currently, the many individuals enjoy some type of health insurance coverage, but there are approximately 46 million Americans without health insurance or about 16% of the population. To begin, the problem of asymmetric information leads to an increase in the cost for medical treatment. This is because individuals seek medical treatment knowing beforehand that they are without insurance and are incapable of paying medical costs. This forces hospitals to shift costs to those who are insured so that the hospital can cover its expenditures. Also, insured individuals behave in such a manner that moral hazard is present. Because the individuals with insurance know that they are not responsible for the bulk of their medical costs, they are more likely to seek unnecessary treatments.

Thus, this increases expenditures for the insurance company and leads to adverse selection of health care insurance coverage. At this point, the insurance company becomes meticulously selective in regards to awarding insurance coverage to individuals.

Those that do not meet qualifications are simply not insured, and the cycle continues.

Doctors are also susceptible to adverse selection. By providing services out of a private office rather than a hospital, physicians are able to choose their patients; whereas in a hospital, they are required to treat all patients. As expected, a doctor treats only those patients who can afford treatment when operating from a personal office. This presents a major problem to hospitals that rely on doctors to bring in patients. With

doctors leaving the hospitals to practice medicine independently, hospitals must adopt new strategies to recruit doctors to replace vacant positions.

There are possible solutions to alleviate the problems associated with health care affordability. One possible solution is to provide incentives for doctors to remain in the hospitals rather than practice independently. The major reason most doctors remain in hospitals currently is because hospitals provide the means to perform certain medical treatments. Without the hospital, it would be difficult for doctors to personally finance the appropriate equipment that is needed to perform the certain medical treatments. To address the root problem of affordability, if health care was made available to all citizens then hospitals would not have to practice cost-shifting so frequently. At the same time, insurance companies could reward those who use their coverage in an appropriate fashion instead of abusing their coverage. Finally, hospitals might provide more visible means of pricing so that individuals can easily obtain pricing information. This would increase the competition among hospitals and drive down prices towards an equilibrium rate.

Shangri-La

Affordability presents a major problem to the residents of Shangri-La as well.

These citizens are posed with a slightly different scenario in terms of paying for health care costs. In fact, 83% of rural Chinese citizens must save frugally to pay for medical treatment from personal accounts because they are without any health care insurance.

Currently, this system of self-payment is failing miserably because individuals in these rural areas of China simply do not possess the resources to afford personal medical costs.

Shangri-La may be able to use its tourism industry as leverage to convince the Chinese government to allow insurance companies to enter the area and provide insurance plans

so that more individuals could have affordable health care coverage. Consequently, more doctors would enter the market because they would have the ability to be paid for their services, which would decrease high volume problems in area hospitals.

Another potential solution to lessen the negative impacts of self-pay health care would be to encourage preventative health care rather than treatment health care services.

As was present in the 1960’s, Chinese citizens prospered from health education services from barefoot doctors because general health information was provided in a cost-efficient manner. This would reduce the amount that Shangri-La families are forced to save because preventative health care would be much more affordable.

In conclusion, through the comparison of the Blount County health care system to that of Shangri-La, numerous potential benefits have been discovered. As the world enters a new era in health care, it will be interesting to observe how these two world superpowers chose to provide health care services for its people. It is reassuring to know that throughout history mankind has repeatedly overcome the challenges that have been presented from the health aspect of human life. In the future, the health of human beings will rest in the hand of individuals, medical professionals, and governments, who will be given the crucial task of discovering new and improved ways to better the health of its fellow man. As the twenty-first century develops, health care is among the top priorities for virtually every country in the world. As the remarks by Samuel Johnson notes at the beginning of this chapter, health care is a vital necessity for humanity. As a result, it needs to be treated as a right of citizens worldwide to experience quality health care.

Thus, it seems that it is justifiable to claim that because individual health has such an immense impact on a community in regards to other residents’ health, workforce

productivity, and cost of health care in the community, that health care should be a right rather than a privilege for citizens of the community.

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