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  • 1. NRSE 6002 Fall 2012
  • 2.  High technology Sophisticated institutions Leading edge research High level training for health professionals
  • 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. • 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.  6,200 hospitals 16,700 nursing homes 5,400 mental health facilities 13,500 home health agencies 1,200 FQHCs 3,400 RHCs
  • 6.  142 MD and DO schools 54 dental schools 80 pharmacy schools 1,500 nursing schools (all levels)
  • 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. What’s our his o ?
  • 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.  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.  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. • Urbanization• Science and technology• Rise of hospitals• Cultural authority• Maintenance of independent (non-employee) status through organization and cohesiveness• Licensing• Educational reform
  • 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.  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.  Let’s discuss!
  • 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.  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.  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.  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.  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.  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.  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.  Health Insurance and Portability and Affordability Act, 1996 Balanced Budget Act,1997 President Clinton’s health care reform attempt
  • 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.  http://money.cnn.com/magazines/fortune/fo rtune500/2010/performers/companies/profi ts/ Driven by profits Driven by technology
  • 26. This is America, isn’t it?
  • 27.  Uninsured and underinsured do not have access to care (access) Costs continue to skyrocket (cost) Outcomes lag behind other developed countries (quality)
  • 28. Uninsured 15%Employer- Medicaid/Sponsored Other PublicInsurance 13% 52% Medicare 14% Private Non- Group 5%
  • 29. Uninsured 17% Medicaid/Other Public Employer- 18% sponsored Insurance 60% Private Non- group 5%
  • 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.  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. Why are we arguing about thePPACA so hard?
  • 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.  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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