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The U.S. Healthcare System: Origins, Organization and Opportunities




The U.S. Healthcare System: Origins, Organization and Opportunities

Joel Shalowitz

ISBN: 978-0-470-63152-2 July 2019 Jossey-Bass 670 Pages


Provides a diverse, multi-faceted approach to health care evaluation and management

The U.S. Health Care System: Origins, Organization and Opportunities provides a comprehensive introduction and resource for understanding healthcare management in the United States. It brings together the many “moving parts” of this large and varied system to provide both a bird’s-eye view as well as relevant details of the complex mechanisms at work. By focusing on stakeholders and their interests, this book analyzes the value propositions of the buyers and sellers of healthcare products and services along with the interests of patients.

The book begins with a presentation of frameworks for understanding the structure of the healthcare system and its dynamic stakeholder inter-relationships. The chapters that follow each begin with their social and historical origins, so the reader can fully appreciate how that area evolved. The next sections on each topic describe the current environment and opportunities for improvement.   

Throughout, the learning objectives focus on three areas: frameworks for understanding issues, essential factual knowledge, and resources to keep the reader keep up to date.

Healthcare is a rapidly evolving field, due to the regulatory and business environments as well as the advance of science. To keep the content current, online updates are provided at: www.HealthcareInsights.MD. This website also offers a weekday blog of important/interesting news and teaching notes/class discussion suggestions for instructors who use the book as a text.

The U.S. Health Care System: Origins, Organization and Opportunities is an ideal textbook for healthcare courses in MBA, MPH, MHA, and public policy/administration programs. In piloting the content, over the past several years the author has successfully used drafts of chapters in his Healthcare Systems course for MBA and MPH students at Northwestern University. The book is also useful for novice or seasoned suppliers, payers and providers who work across the healthcare field and want a wider or deeper understanding of the entire system.




Chapter 1 Understanding and Managing Complex Healthcare Systems

I Definitions

II Health System Structure and Features

III Strategic Planning

A Stakeholders

B Health System Tradeoffs and Value Propositions

Chapter 2 Determinants of Utilization of Healthcare Services and Products

I Reasons Stakeholders Seek Healthcare

II Patient Characteristics That Influence Care-seeking

III Reducing Patient Demand for Healthcare

IV Consumer Behavior-Healthcare Market Segmentation

V Provider-Induced Demand for Healthcare

VI Summary

Chapter 3 Introduction to Managerial Epidemiology

I Introduction

II Definitions and Use of Principles

III Clinical Study Designs

IV Summary

Chapter 4 Hospitals and Health Systems

I A Brief History of Western Hospitals

II American Hospital Expansion in the 20th Century

III Hospital Definition and Classifications

A Definition

B Ways hospitals may be classified and special related issues

1 Size

2 Level of Care (Including Teaching and Non-Teaching Hospitals)

3 Corporate Status/Sponsorship (for Profit Versus Non-Profit)

4 Public/Private Status

5 General/Specialty Hospitals

6 Location

7 Hospital Systems

a Wholly Owned/Singly Managed Systems

b Alliances

c Group Purchasing Organizations(GPOs)

8 Physician-Owned Hospitals

9 Safety Net Providers

a Disproportionate Share Hospitals (DSH)

b Medicare Dependent Hospitals (MDH)

c Sole Community Hospitals (SCH)

d Critical Access Hospitals (CAH)

10 Religious-Sponsored (Faith-based) Hospitals

IV Hospital Inpatient Payment Methods

V Organized (Integrated) Delivery Systems/ Accountable Care Organizations (ACOs)

VI Governance

VII Summary

Chapter 5 Healthcare Professionals

I Physicians

A History of Western Medical Care

B History of American Medical Care

C Current Status of Medical Training

1 Admissions

2 Curriculum

3 Cost

4 Post Graduate Training (residency)

5 Fellowship

6 Board Certification

D Licensure

E Shortage of Physicians

F Employment status

G Summary

II Nurses

A Registered Nurses

B Nurse Practitioners

C Nurse Anesthetists

D Midwives

III Physician Assistants

A Education and Certification

B Physician Versus NP/PA Care

IV Summary

Chapter 6 Payers

I Principles of Health Insurance

II Background and Current Status of Health Insurance in the U.S

A Private Health Insurance

1 Overview

2 Origins and current status of Private Health Insurance in the U.S

a Development of Employer-Sponsored Health Insurance

b Blue Cross/Blue Shield Plans

c Tax Exempt Status of Health Insurance

d Acceleration of Employer-Sponsored Insurance

e Regulation of Insurance and the McCarran-Ferguson Act

f Employee Retirement and Income Security Act (ERISA)

g Consolidated Omnibus Reconciliation Act (COBRA)

h Health Insurance Portability and Accountability Act (HIPAA- Insurance Provisions)

i Personal Healthcare Spending Accounts (Medical Savings Accounts, Health Savings Accounts, Flexible Spending Accounts and Health Reimbursement Arrangements)

j Voluntary Employee Beneficiary Association (VEBA)

k Patient Protection and Affordable Care Act (ACA)

B Medicare

1 Overview and Eligible Populations

2 Structure, Governance and Funds Flow

3 Part A

4 Part B

5 Part C (Medicare Advantage)

6 Part D

7 End Stage Renal Dialysis (ESRD) Program

8 Summary

C Medicaid

1 Background

2 Eligibility

3 Benefits

4 Funding and Expenditures

5 340B Program

6 Cost Control Initiatives

D Children's Health Insurance Program (CHIP)

E Other Federally Sponsored Programs

1 Veterans Healthcare System

2 Active Military/Retirees and Dependents (TRICARE)

3 Federal Employees (Federal Employee Health Benefit Program: FEHBP)

F Managed Care

1 Background

2 Definitions and their Implications (With a focus on Health Maintenance Organizations)

3 Types of Health Maintenance Organizations (HMOs)

4 Distribution of HMO Premiums and its Behavioral Implications

5 Disease Management

6 Preferred Provider Organizations (PPOs)

7 Point of Service (POS) Plans

8 Stakeholder Requirements and Desires for Managed Care Success

9 Current Trends

G Summary

Chapter 7 Healthcare Technology

I Definition and Frameworks for Study

II Major Trends in Healthcare Technology

A Safety

B History of Safety Problems and Corrective Legislation

C Bringing Healthcare Technology to Market

D Evolving Industry Structure

E Globalization

F Generics

G Specialty Pharmaceuticals and Cost-Containment Tactics

H Patents

I Genomics and Precision Medicine

J Disruptive Innovation

III Healthcare technology’s Contribution to Costs by Stage of Care

A Overview

B Quality Adjusted Life Years (QALYs)

C Core cost issues

D Prevention

E Screening

F Diagnosis

G Treatment

IV Other Healthcare Technology Issues

A Religious Issues

B Ethical Issues

C End-of-Life Costs

D Media’s Role in Increasing Technology Costs

E Malpractice and Defensive Medicine

V Summary

Chapter 8 Information Technology

I Introduction

II Definitions

III Background and Key Issues

A Collection, Classification and Ordering of Data

B Terminology and Coding

C Interoperability

1 Introduction and Definition

2 General Background

3 Applications to Healthcare

a Technological Solutions for Data Exchange in Healthcare

b Governmental Initiatives

c Private Initiatives

d Health Information Exchanges

D Certification

E Privacy and Security of Information

F Management Considerations

G Other Issues and Trends

1 Telehealth/Telemedicine

2 Block Chain

3 Cloud-Based Services

4 Artificial Intelligence/Voice Recognition

5 Industry Consolidation

6 Expanding Patient’s Access to and Control of their Data

7 Administrative Simplification

IV Summary

Chapter 9 Quality and Safety

I Introduction

II History of Healthcare Quality and Development of Key Concepts and Institutions

III Quality of Care and the Public’s Health

A Centers for Disease Control and Prevention (CDC)

B Healthy People

IV Definition of quality

V Key Questions for Successful Evaluation and Implementation of Quality Measures

VI Volume/Quality Relationship

VII Managing Quality Improvement

VIII Value Propositions

IX Summary