NRSE 6002 Fall 2012
   High technology   Sophisticated institutions   Leading edge research   High level training for health professionals
•   Lack of standardized payment system•   Unequal access for citizens•    No central coordinating agency•   Wide array of...
•   10 million people employed in health care•   664,000 MDs•   37,000 Dos•   2 million nurses•   162,000 dentists•   200,...
   6,200 hospitals   16,700 nursing homes   5,400 mental health facilities   13,500 home health agencies   1,200 FQHC...
   142 MD and DO schools   54 dental schools   80 pharmacy schools   1,500 nursing schools (all levels)
   1,000 commercial health insurance    companies   70 Blue Cross/Blue Shield plans   750 health maintenance organizati...
What’s our his o   ?
   Women cared for the sick   Healers, herbalists, midwives   Passed traditions and knowledge from    generation to gen...
   Physicians were rising in Europe, but not in    America   Until 1800s, training was by apprenticeship   Basic scienc...
   In 1800, 4 medical schools in US   In 1850, there were 42   AMA formed in 1847   Reform of medical education began ...
•   Urbanization•   Science and technology•   Rise of hospitals•   Cultural authority•   Maintenance of independent (non-e...
   Nursing arose from healing and religious    traditions   Development of nursing entwined with status    of women over...
   Apprenticeship   Hospital schools   Goldmark Report (1923) found nursing    education inadequate in hospital program...
   Let’s discuss!
   Earliest hospitals in US were almshouses or    were to isolate people with infectious disease    or mental illness   ...
   Originated to assure clean water, control    epidemics   Public health nursing gained strength   Gradually took over...
   1916 to 1920   Attempts by social reformers in 16 states to    pass a bill requiring compulsory “health    insurance”...
   Effects of Great Depression on hospitals and    physicians   Hospitals started a pre-payment plan   Physician groups...
   1935 – Social Security Act   1946 – Hill-Burton Act   1952 – failed health care reform under    President Truman   ...
   Attempts to bring more system-ness through    National Health Planning Act of 1974   Rise of HMOs    ◦ HMO Act of 197...
   Rise of for-profit health care providers and    organizations   Increasing corporate dominance   Vertical and horizo...
   Health Insurance and Portability and    Affordability Act, 1996   Balanced Budget Act,1997   President Clinton’s hea...
   “A medical care system that had begun to    attract investors and in which business    interests had started to re-sha...
   http://money.cnn.com/magazines/fortune/fo    rtune500/2010/performers/companies/profi    ts/   Driven by profits   D...
This is America, isn’t it?
   Uninsured and underinsured do not have    access to care (access)   Costs continue to skyrocket (cost)   Outcomes la...
Uninsured                 15%Employer-               Medicaid/Sponsored              Other PublicInsurance                ...
Uninsured          17% Medicaid/Other Public                    Employer-   18%                    sponsored              ...
   66% uninsured families have 1or more full    time worker(s)   67% uninsured families below 200% poverty    level   I...
   Patient Protection and Affordable Care Act    (March 23, 2010)    ◦ Far reaching changes to all aspects of health care...
Why are we arguing about thePPACA so hard?
   Health care as            Health care as    economic model             social resource   Assumes free              ...
   Individual              Collective    responsibility for       responsibility for    health                   health...
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SUSHCS

  1. 1. NRSE 6002 Fall 2012
  2. 2.  High technology Sophisticated institutions Leading edge research High level training for health professionals
  3. 3. • Lack of standardized payment system• Unequal access for citizens• No central coordinating agency• Wide array of service settings that are not inter-connected• Few universal quality standards• Greater proportion of total economic output• Poorer outcomes than many developed countries
  4. 4. • 10 million people employed in health care• 664,000 MDs• 37,000 Dos• 2 million nurses• 162,000 dentists• 200,000 pharmacists• 700,000 health care administrators• 500,000 rehab therapists
  5. 5.  6,200 hospitals 16,700 nursing homes 5,400 mental health facilities 13,500 home health agencies 1,200 FQHCs 3,400 RHCs
  6. 6.  142 MD and DO schools 54 dental schools 80 pharmacy schools 1,500 nursing schools (all levels)
  7. 7.  1,000 commercial health insurance companies 70 Blue Cross/Blue Shield plans 750 health maintenance organizations 1,050 preferred provider organizations Self-insured employers Federal government State governments
  8. 8. What’s our his o ?
  9. 9.  Women cared for the sick Healers, herbalists, midwives Passed traditions and knowledge from generation to generation Care centered in the home Care given by family and community members
  10. 10.  Physicians were rising in Europe, but not in America Until 1800s, training was by apprenticeship Basic science research was centered in Europe American physicians focused on applied medicine – “practical” techniques Medical Journal
  11. 11.  In 1800, 4 medical schools in US In 1850, there were 42 AMA formed in 1847 Reform of medical education began in the 1870’s and turned radically in 1910
  12. 12. • Urbanization• Science and technology• Rise of hospitals• Cultural authority• Maintenance of independent (non-employee) status through organization and cohesiveness• Licensing• Educational reform
  13. 13.  Nursing arose from healing and religious traditions Development of nursing entwined with status of women over the centuries Nightingale ushered in era of “modern” nurse in 1860 NC first state to license “registered nurses” in 1903 State practice acts formalized profession
  14. 14.  Apprenticeship Hospital schools Goldmark Report (1923) found nursing education inadequate in hospital programs Shift to college and university education initiated in 1893 and continues today
  15. 15.  Let’s discuss!
  16. 16.  Earliest hospitals in US were almshouses or were to isolate people with infectious disease or mental illness General hospitals developed in response to ◦ Urbanization ◦ Technology ◦ Medical specialization By 1900, 4,000 hospitals were in operation
  17. 17.  Originated to assure clean water, control epidemics Public health nursing gained strength Gradually took over immunizations, communicable disease, sanitation Public health remained separate from physician practice
  18. 18.  1916 to 1920 Attempts by social reformers in 16 states to pass a bill requiring compulsory “health insurance” for workers Organized labor against it AMA “studied” it No surprise – no success
  19. 19.  Effects of Great Depression on hospitals and physicians Hospitals started a pre-payment plan Physician groups started a pre-payment plan for physician services in the hospital, mainly surgery Private companies saw their success and joined in – and a new industry was born
  20. 20.  1935 – Social Security Act 1946 – Hill-Burton Act 1952 – failed health care reform under President Truman 1965 – Medicare and Medicaid passed in Lyndon Johnson’s vision for the Great Society ◦ Title VIII and Title XIX of the Social Security Amendment of 1965
  21. 21.  Attempts to bring more system-ness through National Health Planning Act of 1974 Rise of HMOs ◦ HMO Act of 1973 Rising costs National Health Planning Act of 1974 HMO Act of 1973
  22. 22.  Rise of for-profit health care providers and organizations Increasing corporate dominance Vertical and horizontal integration of health care organizations Especially in 80s, private sector assumed substantial control of health care delivery
  23. 23.  Health Insurance and Portability and Affordability Act, 1996 Balanced Budget Act,1997 President Clinton’s health care reform attempt
  24. 24.  “A medical care system that had begun to attract investors and in which business interests had started to re-shape the behaviors of doctors and health care facilities…” ◦ Arnold Relman, MD ◦ Editor-in-Chief, New England Journal of Medicine, 1980
  25. 25.  http://money.cnn.com/magazines/fortune/fo rtune500/2010/performers/companies/profi ts/ Driven by profits Driven by technology
  26. 26. This is America, isn’t it?
  27. 27.  Uninsured and underinsured do not have access to care (access) Costs continue to skyrocket (cost) Outcomes lag behind other developed countries (quality)
  28. 28. Uninsured 15%Employer- Medicaid/Sponsored Other PublicInsurance 13% 52% Medicare 14% Private Non- Group 5%
  29. 29. Uninsured 17% Medicaid/Other Public Employer- 18% sponsored Insurance 60% Private Non- group 5%
  30. 30.  66% uninsured families have 1or more full time worker(s) 67% uninsured families below 200% poverty level Individuals between age 30 and 54 comprise the largest group of uninsured
  31. 31.  Patient Protection and Affordable Care Act (March 23, 2010) ◦ Far reaching changes to all aspects of health care system ◦ http://www.kff.org/healthreform/upload/8061.pdf
  32. 32. Why are we arguing about thePPACA so hard?
  33. 33.  Health care as  Health care as economic model social resource Assumes free  Requires market position government Market-based involvement demand for  Assumes services government led Services provided position on ability to pay  Ability to pay not Access is reward for necessary personal effort  Access is a right
  34. 34.  Individual  Collective responsibility for responsibility for health health Benefits based on  Basic benefits for individual everyone purchasing  Strong obligation to Limited obligation collective good to collective good  Public solutions Private solutions  Planned rationing Rationing based on of health care ability to pay

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