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Changing the U.S. Health Care System: Key Issues in Health Services Policy and Management, 4th Edition

Changing the U.S. Health Care System: Key Issues in Health Services Policy and Management, 4th Edition

Gerald F. Kominski

ISBN: 978-1-118-41890-1 November 2013 Jossey-Bass 846 Pages




The Fourth Edition of Changing the U.S. Health Care System addresses the key topics in health care policy and management, presenting evidence-based views of current issues. Each chapter is written by an expert in the field who integrates evidence to explain the current condition and presents support for needed change. The book examines all the levers in the setting and implementation of health policy, and includes extensive coverage of impact of the Affordable Care Act, particularly on Medicare, Medicaid, and large and small group insurance markets. Also new to this edition is expanded coverage of nursing, disease management, mental health, women's health, children's health, and care for the homeless.

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Figures and Tables xv

Foreword to the Third Edition xix

Foreword to the Fourth Edition xxi

The Editor xxv

The Authors xxvii

Introduction and Overview xliii

Acknowledgments lvii


1 The Patient Protection and Affordable Care Act of 2010 3
Gerald F. Kominski

Learning Objectives 3

Events Leading to the Enactment of the ACA 4

Major Provisions of the ACA 7

Future Directions 20

Summary 25

Key Terms 26

Discussion Questions 28

2 Improving Access to Care 33
Ronald M. Andersen, Pamela L. Davidson, Sebastian E. Baumeister

Learning Objectives 33

Understanding Access to Health Care 34

Future Directions 60

Summary 63

Key Terms 63

Discussion Questions 64

3 Racial and Ethnic Disparities in Health Status 71
Antronette K. Yancey, Roshan Bastani, Beth A. Glenn

Learning Objectives 71

Epidemiology of Health Disparities 73

Factors Underlying Chronic Disease-Related Disparities 82

Future Directions 92

Summary 94

Key Terms 94

Discussion Questions 95

4 Racial and Ethnic Disparities in Health Care 103
Arturo Vargas Bustamante, Leo S. Morales, Alexander N. Ortega

Learning Objectives 103

Definition of Disparity in Health Care 105

Historical Overview of Disparities in Medical Care 109

Scientific Evidence of Disparities in Health Care 115

Future Directions 122

Summary 125

Key Terms 126

Discussion Questions 126

5 Multilevel Social Determinants of Health 135
Ninez A. Ponce, Michelle Ko

Learning Objectives 135

Policy Frameworks for Social Determinants of Health 137

Mechanisms by Which Social Context Affects Health Care 142

Future Directions 147

Summary 148

Key Terms 149

Discussion Questions 150

6 Public Health Insurance 157
Shana Alex Lavarreda, E. Richard Brown

Learning Objectives 157

Medicare, Medicaid, and CHIP 159

Who is Left Out of Public Coverage? 169

Enactment of the Affordable Care Act of 2010: A Political Success Story 179

Future Directions 183

Summary 183

Key Terms 184

Discussion Questions 185

7 Private Health Insurance 191
Nadereh Pourat, Gerald F. Kominski

Learning Objectives 191

Evolution of Private Health Insurance 192

Concepts in Private Health Insurance 194

Employment-Based Health Insurance 200

Individually Purchased Health Insurance 207

Significant Trends in Private Health Insurance 208

Future Directions 213

Summary 216

Key Terms 216

Discussion Questions 218


8 Measuring Health Care Expenditures and Trends 225
Thomas H. Rice

Learning Objectives 225

Measuring Health Care Expenditures 226

Trends in Health Care Expenditures 233

Future Directions 239

Summary 239

Key Terms 242

Discussion Questions 243

9 Containing Health Care Costs 245
Thomas H. Rice, Gerald F. Kominski

Learning Objectives 245

Framework 246

Future Directions 263

Summary 264

Key Terms 264

Discussion Questions 265

10 Promoting Pharmaceutical Access While Controlling Prices and Expenditures 269
Stuart O. Schweitzer, William S. Comanor

Learning Objectives 269

The Problem of Drug Expenditures 271

Interpreting Pharmaceutical Price Data 275

International Price Comparisons 279

Determining Drug Prices 281

Approaches for Containing Pharmaceutical Costs 289

The Link Between Pharmaceutical Expenditures and Research 293

Recent Events Surrounding Pharmaceutical Costs and Access 294

Future Directions 298

Summary 298

Note 299

Key Terms 299

Discussion Questions 300


11 Measuring Health-Related Quality of Life and Other Outcomes 307
Patricia A. Ganz, Ron D. Hays, Robert M. Kaplan, Mark S. Litwin

Learning Objectives 307

Definition, Conceptualization, and Measurement of Quality of Life 310

Contributions From the Literature 318

Comparative Effectiveness Research 328

Future Directions 331

Summary 332

Key Terms 333

Discussion Questions 334

12 Evaluating the Quality of Care 343
Elizabeth A. McGlynn

Learning Objectives 343

The Multiple Dimensions of Quality 344

Criteria for Evaluating Quality Measures 345

A Conceptual Framework for Quality Assessment 347

Structure 348

Process 355

Outcomes 365

Future Directions 371

Summary 372

Key Terms 373

Discussion Questions 374

13 Public Release of Information on Quality 381
Elizabeth A. McGlynn, John L. Adams

Learning Objectives 381

Public Information on Quality 383

Some Methodological Issues in Performance Reporting 391

What is Known About the Impact of Public Reporting? 402

Future Directions 406

Summary 406

Key Terms 407

Discussion Questions 408

14 Health Care Information Systems 413
Jeff Luck, Leah J. Vriesman, Paul Fu Jr.

Learning Objectives 413

Information Systems and Informatics 414

Benefits, Implementation Barriers, and Federal Policy Responses 414

Applications of Information Systems by Health Care Providers 417

Public Health Informatics 434

Applications of Information Systems by Health Plans and Payers 438

Future Directions 441

Summary 445

Key Terms 445

Discussion Questions 446

15 Performance Measurement of Nursing Care 455
Jack Needleman, Ellen T. Kurtzman, Kenneth W. Kizer

Learning Objectives 455

Why Measure Nursing Performance? 455

The Scope of Nursing’s Contribution to Inpatient Hospital Care 457

Issues in Constructing Nursing-Sensitive Performance Measures 461

Measuring Nursing Performance 463

Measuring Nursing Performance: The State of the Science 478

Future Directions 485

Summary 486

Key Terms 487

Discussion Questions 487


16 Long-Term Services and Supports for the Elderly Population 495
Steven P. Wallace, Nadereh Pourat, Linda Delp, Kathryn G. Kietzman

Learning Objectives 495

Institutional Care 497

Community-Based Services 502

Informal Care 507

Workers in the Long-Term Care System 509

Future Directions 516

Summary 517

Note 517

Key Terms 517

Discussion Questions 518

17 HIV and AIDS in the Twenty-First Century 523
Erin G. Grinshteyn, William E. Cunningham

Learning Objectives 523

The Changing Epidemiology and Clinical Treatment of HIV/AIDS 525

Prevention and Education 538

Policy Implications and Research Needs for Management, Planning, and AIDS Policy 543

Future Directions 546

Summary 547

Key Terms 548

Discussion Questions 550

18 Children’s Health 559
Moira Inkelas, Neal Halfon, David Lee Wood

Learning Objectives 559

Special Health Needs of Children 561

Health Service Delivery for U.S. Children 564

Financing Children’s Health Care 569

Improving the Child Health System 576

Future Directions 585

Summary 585

Key Terms 586

Discussion Questions 587

19 Homeless Persons 593
Lisa Arangua, Lillian Gelberg

Learning Objectives 593

A Profile of the Homeless 594

Health Status 597

Mental Illness and Substance Abuse 604

Use of Physical Health Services 606

Use of Mental Health and Substance Abuse Services 608

Barriers to Health Care 609

Future Directions 610

Summary 612

Key Terms 612

Discussion Questions 613


20 Changing the Health Care Delivery System 623
Nadereh Pourat, Hector P. Rodriguez

Learning Objectives 623

Conceptual Framework: Intervention and Innovations to Correct System Failures 625

Future Directions 641

Summary 642

Key Terms 642

Discussion Questions 644

21 Medicare Reform 651
Gerald F. Kominski, Jeanne T. Black, Thomas H. Rice

Learning Objectives 651

Origin and Philosophy of Medicare 652

Evolution of Medicare 656

Is Medicare Facing a Crisis? 663

Future Directions 670

Summary 673

Key Terms 674

Discussion Questions 675

22 Public Health and Clinical Care 681
Jonathan E. Fielding, Lester Breslow, Steven M. Teutsch

Learning Objectives 681

Public Health’s Mission and Scope 682

Prevention In Clinical Care Services 685

Public Health and Provision of Clinical Care Services 689

Direct Medical Service Delivery by Government 691

Future Directions 692

Summary 699

Key Terms 700

Discussion Questions 700

23 Strengthening the Safety Net 703
Dylan H. Roby

Learning Objectives 703

Defining the Safety Net 704

Ensuring Access to Care for the Poor, Uninsured, and Underserved 705

Financing the Safety Net 706

Size and Scope of the Safety Net 707

Reducing Costs 715

Improving Quality 716

Future Directions 719

Summary 719

Key Terms 720

Discussion Questions 721

24 Ethical Issues in Public Health and Health Services 727
Pauline Vaillancourt Rosenau, Ruth Roemer, Frederick J. Zimmerman

Learning Objectives 727

Overarching Public Health Principles: Our Assumptions 730

Ethical Issues in the Allocation of Resources 730

Ethical Issues in Research 737

Ethical Issues in Economic Support 738

Ethical Issues in Management of Health Services 740

Ethical Issues in Delivery of Care 741

Future Directions 744

Summary 745

Key Terms 746

Discussion Questions 747

Index 753