Georgia Southern University
                      Jiann-Ping Hsu College of Public Health
                     PUBH 6134 –...
Secondary Text:       Additional articles, supplemental materials, and URLs/website
                      addresses will b...
•       Discuss values and ethical dilemmas in health care that are inherent in efforts to
           control costs, while...
and on the Web Course.          document and on the Web
                                                                  ...
Grading:                   1Weighting of assignments for purposes of grading will be as
                           follows...
The following point scale will be utilized in grading:

                          900 +          =       A
               ...
Quizzes and Final exam: There will be three quizzes and a final exam in the course. The
quizzes and the final exam will ut...
transmit, display, or record notes in or from class without the
                        express written permission of the ...
4. Realize the importance of and know the intricacies of the health care system

   5. Have an overview of health care in ...
c) Prepare for Online Chat and Discussion Board for week (refer to syllabus
          online chat schedule) by reviewing q...
13. What is the difference between national health insurance (NHI) and national
health system (NHS)? (Comprehension: 2 poi...
1. Ability to pay (health insurance)
2. Availability of services (delivery), for example, certain rural and remote areas l...
• Global budgets are used to determine the national healthcare expenditures in advance.
• Healthcare resources are allocat...
3. Socialized health insurance (SHI)—health care is financed through government-
mandated contributions by employers and e...
Managed care also seeks to achieve better efficiencies in these areas by integrating the
basic functions
of healthcare del...
• Standards of participation—Minimum quality standards established by government
regulatory agencies to certify providers ...
ii. Cost Quality Access Model Assistant Presentation
       b) View this Week’s Lecture
       c) Attend this week’s Live ...
8. The Blum model points to four key determinants of health. Discuss their
implications for healthcare delivery. (Comprehe...
b: Identify the members of the community that should be involved in addressing
this community health problem. Why did you ...
• It has established the supremacy of curative medicine over the health
       promotion/disease prevention model (HPDP)
 ...
•   Risk factor—an attribute that increases the likelihood (probability) that people
           would develop a disease or...
• Lifestyle—behaviors, attitudes toward health
• Heredity—current health and lifestyle practices are likely to impact futu...
• Activities of daily living (ADLs)—Measure a person’s ability to function independently,
especially in reference to one’s...
• Illness—Recognized by means of a person’s own perceptions and an evaluation of how
he or she feels. For example, an indi...
• Social contacts—Evaluated in terms of the number of social contacts or social activities a
person engages in within a sp...
c) Read Ten Great Achievements of Public Health (webpage html file) found in
       the Web Course.

Lecture Assignments:
...
5. Discuss the relationship of dependency within the context of the medical
profession’s cultural and legitimized authorit...
4. You are a lead policy analyst for the Centers for Medicare and Medicaid Services
(CMS; formerly known as the Health Car...
• Urbanization—proximity (reduced opportunity costs), change in the family’s
social structure
        • Science and techno...
Organized medicine kept private practice separated from public health for fear that it
would invite government interventio...
Main reasons why proposals favoring NHI have been defeated in the United States
(differences between Europe and the United...
PROTOTYPES OF MANAGED CARE
       Contract practice
               • Direct contracting with industry in remote areas, use...
• Balance bill—The practice of billing the patient for the balance remaining after
insurance has paid its share of the tot...
End Week 3

WEEK 4

Start Week 4

Objectives: Chapter 4

   1. To recognize the different types of health service professi...
Review Questions (based on your points selections):
      a) Complete/Answer Review Questions for this week’s chapter and ...
1. What settings and challenges (situations for management and leadership) are possible
for entry to middle level of healt...
2. LPN (LVN)—1 to 2 years at a community college

Impact of decline in hospital stay:
       Growth of other settings such...
1. Technologists and therapists—PTs, OTs, Speech therapists, Dieticians, Medical
technologists, etc.
       2. Technicians...
• Dentists—The major providers of dental care and must be licensed to practice. Their
major roles are to diagnose and trea...
decades to include drug product education and serving as experts on specific drugs, drug
interactions, and generic drug su...
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
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PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
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PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
PUBH 6134 - Health Services Administration
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PUBH 6134 - Health Services Administration

  1. 1. Georgia Southern University Jiann-Ping Hsu College of Public Health PUBH 6134 – Health Services Administration Fall 2007 Instructor: Renée Hotchkiss, Ph.D. Office: Cottage 215 Phone: (912) 871-1342 E-Mail Address: rhotchkiss@georgiasouthern.edu Office Hours: Tuesdays and Wednesdays 3pm – 6 pm Other times by appointment Web Page: http://www.georgiasouthern.edu/ Class Meets: Monthly on Wednesdays 6:30-9:15 Hollis Building 1118 -- Course schedules can be found at: http://www.collegesource.org/displayinfo/catalink.asp -- Prerequisites: None Web-CT Address: Georgia Southern WebCT Portal Catalog Description: This course examines the structure and functioning of the health care delivery system. Health care organizations including hospitals, long-term care, ambulatory care, managed care, private and public insurance, public health, integrated delivery systems, and other health care providers will be reviewed. The course also examines principles of strategic management applied to health care organizations amid a dynamic/changing environment. . Required Textbook: Delivering Health Care in America, 3d Edition by Shi and Singh; Publisher: Jones and Bartlett, ISBN Number 0763731994.
  2. 2. Secondary Text: Additional articles, supplemental materials, and URLs/website addresses will be supplied by the instructor and students in the course. Program Goals: At the completion of this program the student will be able to: • Contribute to the public health profession through the practice of sound professional public health attitudes, values, concepts and ethics. • Appreciate and facilitate diversity of thought, culture, gender and ethnicity through inter-professional communication and collaboration. • Integrate and apply the crosscutting knowledge and competencies within five core public health areas of knowledge (biostatistics, epidemiology, environmental health sciences, health services administration and social and behavioral sciences. • Demonstrate advanced knowledge and skills necessary for specialized roles within public health, in at least one of the five core areas of public health. • Identify the main components and issues of the organization, financing and delivery of health services and public health systems in the United States. • Describe the legal and ethical basis for public health and health services. • Explain methods of ensuring community health safety and preparedness. • Apply 'systems thinking' for resolving organizational problems. Course Objectives: At the completion of this course the student will be able to: • Define the major components of the health care delivery system and its administration amid the economic, social, technological, and political factors that influence them. • Analyze trends in planning, resource allocation, and health services financing and their effects on consumers, providers, employers, government, and payers. • Describe the professional, economic, social, technological, and legislative influences in health care.
  3. 3. • Discuss values and ethical dilemmas in health care that are inherent in efforts to control costs, while assuring access and quality of care. • Apply a systematic model for analyzing health administration problems, issues, opportunities and threats. Overview of the Content to be Covered During the Semester: Week Topic Readings Assignment 1 Chapter 1 See Weekly Assignments that See Weekly Assignments Meet are attached to this document that are attached to this Aug. 15 and on the Web Course. document and on the Web Course. 2 Chapter 2 See Weekly Assignments that See Weekly Assignments Aug. 22 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 3 Chapter 3 See Weekly Assignments that See Weekly Assignments Aug. 29 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 4 Chapter 4 See Weekly Assignments that See Weekly Assignments Meet are attached to this document that are attached to this Sept. 5 and on the Web Course. document and on the Web Course. 5 Chapter 5 See Weekly Assignments that See Weekly Assignments Sept. 12 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 6 Chapter 6 See Weekly Assignments that See Weekly Assignments Sept. 19 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 7 Chapter 7 See Weekly Assignments that See Weekly Assignments Sept. 26 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 8 Chapter 8 See Weekly Assignments that See Weekly Assignments Meet are attached to this document that are attached to this Oct. 3 and on the Web Course. document and on the Web Course. 9 Chapter 9 See Weekly Assignments that See Weekly Assignments Oct. 10 are attached to this document that are attached to this
  4. 4. and on the Web Course. document and on the Web Course. 10 Chapter 10 See Weekly Assignments that See Weekly Assignments Oct. 17 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 11 Chapter 11 See Weekly Assignments that See Weekly Assignments Oct. 24 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 12 Chapter 12 See Weekly Assignments that See Weekly Assignments Oct. 31 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 13 Chapter 13 See Weekly Assignments that See Weekly Assignments Meet are attached to this document that are attached to this Nov. 7 and on the Web Course. document and on the Web Course. 14 Chapter 14 See Weekly Assignments that See Weekly Assignments Nov. 14 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 15 Final Exam See Weekly Assignments that See Weekly Assignments Nov.28 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. Samples of your work may be reproduced for search purposes and/or inclusion in the professor’s teaching portfolio. You have the right to review anything selected for use, and subsequently ask for its removal. Instructional Methods: Class meetings will be a combination of lecture, class discussion, video lecture, chat room sessions, discussion board, written discussion questions, quizzes, a final examination, computer software demonstration, and work group discussions. Written discussion questions, thought worksheet assignments, quizzes, and a final examination constitute the basis of student evaluation. Exam Schedule and Final Examination: Final Examination: Week 15 of course Quizzes: Refer to Weekly Assignments Schedule
  5. 5. Grading: 1Weighting of assignments for purposes of grading will be as follows: PUBH 6134 HEALTH SERVICES ADMINISTRATION Course Point Determination, Grading Evaluation based on Points and Point Timeline Live Classroom, Week Review Thought Textbook Quizzes Online Chat & Final Exam Total of Questions Worksheet Chapter POINTS Discussion POINTS POINTS Course POINTS POINTS Board POINTS 1 1 34 10 44 2 2 33 10 43 3 3 34 10 50 94 4 4 19 20 10 49 5 5 29 10 39 6 6 25 10 60 95 7 7 26 20 10 56 8 8 25 10 35 9 9 23 10 65 98 10 10 29 10 39 11 11 20 10 30 12 12 25 20 10 75 130 13 13 11 complete 10 complete 21 14 14 17 10 27 15 complete complete complete 400 400 16 complete 0 350 60 140 250 400 1200 1200 Total Points; 900 required for an "A" grade. Grading based on Assignments and participation will be evaluated by Points the instructor and given a percentage grade, then 900 - 1000 A 800 - multiplied by the possible points listed above for each 899.99 B 700 - opportunity. The student selects what opportunities to 799.99 C pursue and complete to determine their ultimate point 600 - total that equates to a grade. 699.99 D 599.99 & below F
  6. 6. The following point scale will be utilized in grading: 900 + = A 800 - 899.99 = B 700 - 799.99 = C 600 - 699.99 = D 599.99 or less = F For calculation of your final grade, all grades above will be included. Your grades will not be posted. Assignments and the final exam presentation will be graded promptly so that students may accurately calculate their grades at any point in time during the semester. There are times when extraordinary circumstances occur (e.g., serious illness, death in the family, etc.). In such circumstances, and/or if you need additional time to satisfactorily complete any course requirement, please consult with the instructor within a reasonable amount of time. Nota Bene: Extensions are not guaranteed and will be granted solely at the discretion of the instructor. Overview of Assignments: Thought Worksheet Assignments: Thought worksheets are due as assigned (see Weekly Assignments schedule) based on the issue or issues corresponding to the content of the course up to that week in the course. Please see the weekly schedule for content areas for completion of the Thought Worksheet. How you think critically, support your thoughts and communicate those ideas are most important to these assignments. Do not get behind in the Thought Worksheet assignments. The Thought Worksheets will be evaluated on 5 criteria: Logic, Consistency, Support, Context and Elements (is the worksheet complete). Review Discussion Questions: Each week/chapter/module will require each student to answer a series of questions. Each week a file named “Student PUBH 6134 Chapter X Review Questions and Answer Comparison System” contains the questions and instructions.
  7. 7. Quizzes and Final exam: There will be three quizzes and a final exam in the course. The quizzes and the final exam will utilize a variety of testing methods to include multiple choice, true and false, short answer and short essay. Information for the exams will come from the main points/topics in the text, lectures, and assignments. Live Classroom, Online Chat and Discussion Board Participation: Each student will receive the points noted on the course points summary (above) when they actively participate in weekly activities, either in person or virtually over the Internet. Important Notes: Philosophy: This course is designed in a way that may be quite different than other courses that you have been exposed to because you will be asked to think critically about the subject matter throughout this semester. All of our activities will focus on helping you to better understand the logic of healthcare service administration, components of care delivery and national policy considerations. You will begin to think like a rational healthcare administrator, like a rational healthcare policy specialist, like a rational provider, and like a rational consumer. You will be asked to continually engage your mind during class and while preparing for class. The textbook will be used as a general resource for the course. You will learn to connect the logic of healthcare service systems (including the organization of healthcare services in the United States, medicine and technology, and patterns of illness and disease and access to healthcare), managed care and private health insurance, providers of health services (including public health, ambulatory healthcare services, hospitals and healthcare systems, long-term care, mental health services, pharmaceuticals, and healthcare professionals), and the assessment and regulation of healthcare services (including health policy and politics, quality assessment and quality improvement, and ethical issues in healthcare services), so that the subject becomes relevant to you. Academic Misconduct: 1As a student registered at this University, it is expected that you will adhere to only the strictest standards of conduct. It is recommended that you review the latest edition of the Student Conduct Code book, as well as the latest Undergraduate & Graduate Catalog to familiarize yourself with the University’s policies in this regard. Your continued enrollment in this course is an implied contract between you and the instructor on this issue; from this point forward, it is assumed that you will conduct yourself appropriately. Academic integrity relates to the appropriate use of intellectual property. The syllabus, lecture notes, and all materials presented and/or distributed during this course are protected by copyright law. Students are authorized to take notes in class, but that authorization extends only to making one set of notes for personal (and no other) use. As such, students are not authorized to sell, license, commercially publish, distribute,
  8. 8. transmit, display, or record notes in or from class without the express written permission of the instructor. Academic Handbook: Students are expected to abide by the Academic Handbook, located at http://students.georgiasouthern.edu/sta/guide/. Your failure to comply with any part of this Handbook may be a violation and thus, you may receive an F in the course and/or be referred for disciplinary action. University Calendar for the Semester: The University Calendar is located with the semester schedule, and can be found at: http://www.collegesource.org/displayinfo/catalink.asp. Attendance Policy: Federal regulations require attendance be verified prior to distribution of financial aid allotments. Attendance will not be recorded after this initial period. One Final Note: The contents of this syllabus are as complete and accurate as possible. The instructor reserves the right to make any changes necessary to the syllabus and course material. The instructor will make every effort to inform students of changes as they occur. It is the responsibility of the student to know what changes have been made in order to successfully complete the requirements of the course. WEEKLY ASSIGNMENTS FOR PUBH 6134 WEEK 1 Start Week 1 Objectives Chapter 1 1. Understand the basics of the U.S. health care system 2. Be able to outline four components of the health care delivery system 3. Be able to differentiate the U.S. health care system and the free market
  9. 9. 4. Realize the importance of and know the intricacies of the health care system 5. Have an overview of health care in four other countries Reading Assignments: a) Chapter 1, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) c) PUBH 6134 Course Syllabus d) Primary Care Coverage 03112006 article (online file in course) e) Review the PUBH 6134 Web Resources file that contains live URL links to websites that will be helpful to you in this course, program and career. Lecture Assignments: a) View the Course Overview and Assignments Presentation including: i. Thought Worksheet Assignment Presentation (in overview) ii. Cost Quality Access Model Assistant Presentation (in overview) b) View “What is Health Administration?” Lecture Video c) View the Week 1 Lecture Video d) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) Complete the Pre-Course Evaluation for this week before you complete any other task for this week b) There are no quizzes this week Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. b) Your next Thought Worksheet Assignment is due in week 3 and the topic for you to analyze is: Universal Healthcare Coverage in the United States. Review Questions (based on your points selections): a) Complete/Answer Review Questions for Chapter 1 and email to instructor by date prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for Chapter 1 and email to instructor by date prescribed in file
  10. 10. c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions at end of week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 34 points available) 1. Why does cost containment remain an elusive goal in US health services delivery? (Synthesis: 4 points) 2. What are the two main objectives of a health delivery system? (Knowledge: 1 point) 3. Name the four basic functional components of the US healthcare delivery system. What role does each play in the delivery of health care? (Knowledge, Comprehension: 2 points) 4. What is the primary reason for employers to purchase insurance plans to provide health benefits to their employees? (Knowledge: 1 point) 5. Why is it that despite public and private health insurance programs, some US citizens are without any coverage? (Application, Synthesis: 4 points) 6. What is managed care? (Knowledge, Comprehension: 2 points) 7. Why is the US healthcare market referred to as “imperfect”? (Synthesis, Evaluation: 5 points) 8. Discuss the intermediary role of insurance in the delivery of health care. (Knowledge, Comprehension: 2 points) 9. Who are the major players in the US health services system? What are the positive and negative effects of the often-conflicting self-interests of these players? (Application: 3 points) 10. What main roles does the government play in the US health services system? (Comprehension: 2 points) 11. Why is it important for healthcare managers, policymakers, and public health professionals to understand the intricacies of the health care delivery system? (Comprehension, Application: 3 points) 12. What kind of a cooperative approach do the authors of the text recommend for charting the future course of the health delivery system? (Comprehension: 2 points)
  11. 11. 13. What is the difference between national health insurance (NHI) and national health system (NHS)? (Comprehension: 2 points) 14. What is socialized health insurance (SHI)? (Knowledge: 1 point) Online Chat and Discussion Board Questions: 1. Why does cost containment remain an elusive goal in U.S. health services delivery? 2. What are the two main objectives of a health delivery system? 3. Name and describe the role of the four basic functional components of the U.S. healthcare delivery system? 4. What is the primary reason for employers to purchase insurance plans to provide health benefits to their employees? 5. Why is it that despite public and private health insurance programs, some U.S. citizens are without any health coverage? 6. What is Managed Care? Summary of Week: CHAPTER 1 A Distinctive System of Healthcare Delivery THE PRIMARY OBJECTIVES OF A HEALTHCARE DELIVERY SYSTEM 1. To enable all citizens to receive healthcare services whenever needed—universal access. 2. To deliver cost-effective services and meet certain pre-established standards of quality (professional or national standards of care). THE QUAD-FUNCTION MODEL Functional components of healthcare delivery: • Financing—to purchase insurance, or to pay for healthcare services consumed • Insurance—to protect against catastrophic risk • Delivery—to provide healthcare services • Payment—to reimburse providers for services delivered ACCESS • Financing and insurance are the key predictors of access • Delivery and payment also influence access (accessibility), but more indirectly Access is determined by four factors:
  12. 12. 1. Ability to pay (health insurance) 2. Availability of services (delivery), for example, certain rural and remote areas lack adequate services 3. Payment, for example, many providers do not accept patients covered under Medicaid because of low reimbursement limits 4. Enablement barriers, for example, lack of transportation; racial, cultural, and language barriers FINANCING AND INSURANCE MECHANISMS • Employer-based health insurance—private • Privately purchased health insurance—private • Government programs—public; Medicare—elderly and certain disabled people; Medicaid—poor (if they meet the eligibility criteria) WHYDO WE HAVE THE UNINSURED? • Unemployed • Employers are not required to offer health insurance • Employees are not required to purchase health insurance • To participate in government programs, people must meet eligibility criteria MANAGED CARE A system of health care delivery that (1) seeks to achieve efficiencies by integrating the basic functions of healthcare delivery, and (2) employs mechanisms to control utilization of medical services and the price at which the services are purchased. Financing—private or public entities, but managed care enables these entities to better manage their healthcare dollars. Two types of financing mechanisms are commonly used: 1. Capitation—For one set fee per member per month (PMPM), the MCO promises to deliver all needed healthcare services. 2. Discounted fees Insurance—MCO assumes risk and acts as an insurance carrier. Delivery—MCO arranges to provide healthcare services to the enrollees, either directly or through contracts. MCO implements various types of controls to manage utilization. Payment—MCO acts as a payer and disburses payments to providers based on capitation or discounted fee arrangements. COST CONTROL IN A NATIONAL HEALTHCARE PROGRAM
  13. 13. • Global budgets are used to determine the national healthcare expenditures in advance. • Healthcare resources are allocated within the budgetary limits: • Reimbursement levels • Availability and dissemination of services and technology PRIMARY CHARACTERISTICS OF THE US HEALTHCARE SYSTEM • No central agency—global budgeting becomes impossible • Partial access—a large segment of the population (roughly 16%) is uninsured • Imperfect (quasi) market—consequences include moral hazard and supplier-induced demand • Third-party insurers and multiple payers—Insurance (commercial insurance companies or managed care organizations) becomes an intermediary function. These intermediary functions result in higher administrative costs. • Multiple third-party payers • Balancing of power among various players prevents any single entity from dominating the system • Legal actions lead to the practice of defensive medicine • Development of new technology creates an automatic demand for its use • New service settings have evolved along a continuum • Quality is no longer accepted as an unachievable goal in the delivery of health care IMPLICATIONS FOR HEALTH SERVICES MANAGERS • Help understand change (shifts occurring in the system) • Enable senior managers to take advantage of opportunities and minimize threats • Help evaluate need for training • Help understand the impact of new regulations NATIONAL HEALTHCARE PROGRAMS Other developed countries have national healthcare programs providing universal access —theoretically, no uninsured. Universal access is provided by a healthcare delivery system that (1) is managed by the government, and (2) provides a defined set of healthcare services to all citizens. Three models of national systems: 1. National health insurance (NHI)—a tax-supported national healthcare program in which services are financed by the government but are rendered by private providers (Canada, for example). 2. National health system (NHS)—a tax-supported national healthcare program in which the government finances and also controls the service infrastructure (for example, Great Britain).
  14. 14. 3. Socialized health insurance (SHI)—health care is financed through government- mandated contributions by employers and employees. Health care is delivered by private providers (for example, Germany, Israel, and Japan). TERMINOLOGY • Access—Refers to the ability of an individual to receive healthcare services when needed. In this context, need is primarily determined by the patient. It is secondarily determined by a referring physician, especially for higher-level services. • Administrative costs—Incidental to the delivery of health services. These costs are not only associated with the billing and collection of claims for services delivered, but also include numerous other costs, such as time and effort incurred by employers for the selection of insurance carriers, costs incurred by insurance and managed care organizations to market their products, time and effort involved in the negotiation of rates, and resources used in the completion and maintenance of medical records. • Balance bill—Refers to the leftover sum that a provider bills to the patient after insurance has only partially paid the charge that was initially billed. • Capitation—A payment mechanism in which all healthcare services are included under one set fee per covered individual. The fee is generally paid per month, hence it is also referred to as per-member-per-month (PMPM). The fee covers all services an enrollee may need during the entire year. A charge is the fee (or price) set by the provider. The charge is the amount the provider generally bills for services delivered. The payer may reimburse the charges only partially, which may necessitate balance billing to the patient. • Defensive medicine—Involves the delivery of services and maintenance of documentation undertaken primarily to guard against the risk of malpractice lawsuits. These additional efforts do not generally add to the quality of care. • Demand—The quantity of health care demanded by consumers based solely on the price of those services. Enabling services, such as transportation or translation services, facilitate access when an individual already has health insurance coverage. • An enrollee—An individual enrolled in a health plan and therefore entitled to receive health services the plan provides. • A free market—Characterized by the unencumbered operation of the forces of supply and demand when numerous buyers and sellers freely interact in a competitive market. • Global budgets—Used to control costs in centrally managed systems. System-wide healthcare expenditures are budgeted. Resources are allocated within the budgetary limits. Availability of services and payments to providers are subject to such budgetary constraints. • Health plan—Two basic meanings: (1) It can refer to any type of health insurance plan. (2) From a macro-systemic perspective, a managed care organization (MCO) responsible for furnishing services under a health plan is also referred to as the health plan, in contrast to an insurance company or carrier for a traditional health insurance plan. • Inpatient care—Refers to a patient who is institutionalized (the state of being in an institution) or to services provided in institutional settings that require an overnight stay. • Managed care—Seeks to “manage” the utilization of medical services, the price at which these services are purchased, and consequently, how much the providers get paid.
  15. 15. Managed care also seeks to achieve better efficiencies in these areas by integrating the basic functions of healthcare delivery. • Medicaid—The government insurance program for the indigent. • Medicare—The government insurance program for the elderly and certain disabled individuals. • Moral hazard—The term used to explain the increased utilization of healthcare services when people have health insurance coverage. • National health insurance (NHI)—A tax-supported health plan that ensures universal access. Services are financed by the government but are rendered by private providers. • National health system (NHS)—A tax-supported health plan that ensures universal access; but in this case, the government also controls the service infrastructure. • Need for health services (in contrast to demand for health services) is based on individual judgment. The patient makes the primary determination of the need for health care and, under most circumstances, initiates contact with the system. The physician may make a professional judgment and determine need for referral to higher-level services. • Outpatient care—Refers to a patient who receives services in an outpatient setting or to the services that are delivered on an outpatient basis. Such services are also referred to as ambulatory services. • Package pricing—The bundling of related services into a package, and charging one flat fee for the package. • Phantom providers—Practitioners who generally function in an adjunct capacity. The patient does not receive direct services from them. They bill for their services separately, and the patients often wonder why they have been billed. Examples include anesthesiologists, radiologists, and pathologists. • Premium cost sharing—Refers to the common practice by employers that require their employees to pay a portion of the health insurance cost. • Primary care—Basic and routine care delivered by a general practitioner. In a managed care system, the primary care physician also makes the determination for the need for higher-level services. • A provider—Can be an individual health care professional, a group, or an institution that delivers healthcare services and receives reimbursement directly for those services. A registered nurse who is employed by a hospital is not a provider since his or her services cannot be billed for reimbursement. The same registered nurse working as a nurse practitioner in private practice could be a provider if he or she can bill for services. • The quad-function model—Includes the key functions of financing, insurance, delivery, and payment. • Reimbursement—The amount paid to a provider by the insurer. The payment may be only a portion of the actual charge. • Single-payer system—Refers to a system in which there is a single payer as opposed to multiple payers. The single payer is generally the government, as is the case in a national health insurance program. • In a socialized health insurance (SHI) system, such as in Germany, health care is financed through government mandated contributions by employers and employees. Health care is delivered by private providers.
  16. 16. • Standards of participation—Minimum quality standards established by government regulatory agencies to certify providers for delivery of services to Medicare and Medicaid patients. • Supplier-induced demand—Refers to the demand for healthcare services created by providers for their own financial benefit. • System—A network of interrelated components that have been designed to work together coherently. • Third party—An intermediary between patients and providers. Third parties carry out the functions of insurance and payment for healthcare delivery. • Uninsured—People who are without health insurance coverage. • Universal access—Means that all citizens have access to at least a basic package of healthcare services. • Utilization—Refers to the quantity of health care consumed. End Week 1 WEEK 2 Start Week 2 Objectives: Chapter 2 1. Understand definitions and differences of health, illness and sickness. 2. Know the determinants of health and health status. 3. Know the American beliefs and values in the delivery of health care. 4. Understand the factors associated with the promotion of health and the prevention of disease. 5. Develop a position on the equitable distribution of health care services. 6. Identify and compute with a formula, the basic measures of health and its utilization. Reading Assignments: a) Chapter 2, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) c) PUBH 6134 Course Syllabus Lecture Assignments: a) View the Course Overview and Assignments Presentation including: i. Thought Worksheet Assignment Presentation
  17. 17. ii. Cost Quality Access Model Assistant Presentation b) View this Week’s Lecture c) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) There are no quizzes this week Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. b) Your next Thought Worksheet Assignment is due in week 3 and the topic for you to analyze is: Universal Healthcare Coverage in the United States of America. Review Questions (based on your points selections): a) Complete/Answer Review Questions for week and email to instructor by date prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for week and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions at end of week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 33 points available) 1. Distinguish between illness and disease. How are these concepts related to the medical model of healthcare delivery? (Application: 3 points) 2. What is the role of health risk appraisal in health promotion and disease prevention? (Comprehension: 2 points) 3. Health promotion and disease prevention may require both behavioral modification and therapeutic intervention. Discuss. (Application: 3 points) 4. Discuss the definitions of health presented in this chapter in terms of their implications for the health delivery system. (Comprehension: 2 points) 5. What implications does early childhood development have for healthcare delivery? (Knowledge: 1 point) 6. What are the main objectives of public health? (Knowledge: 1 point) 7. Discuss the significance of an individual’s quality of life from the health delivery perspective. (Comprehension: 2 points)
  18. 18. 8. The Blum model points to four key determinants of health. Discuss their implications for healthcare delivery. (Comprehension: 2 points) 9. What has been the main cause of the dichotomy in the way physical and mental health issues have traditionally been addressed by the health delivery system? (Knowledge: 1 point) 10. Discuss the main cultural beliefs and values in American society that have influenced healthcare delivery, and how they have shaped the healthcare delivery system. (Application: 3 points) 11. Discuss the main elements of Parsons’s sick role model. What implications does the sick role model have for health services delivery? (Application: 3 points) 12. Briefly describe the concepts of market justice and social justice. In what way do the two principles complement each other and in what way do they conflict in the US system of healthcare delivery? (Comprehension: 2 points) 13. Describe how health care is rationed in the market justice and social justice systems. (Comprehension: 2 points) 14. To what extent do you think the objectives set forth in the Healthy People initiatives can achieve the vision of an integrated approach to healthcare delivery in the United States? (Application: 3 points) 15. How can healthcare administrators and policymakers use the various measures of health status and service utilization? Please illustrate your answer. (Application: 3 points) Online Chat and Discussion Board Questions: 1. What implications does early childhood development have for healthcare delivery? 2. Select one of the priority areas identified by the U.S. Department of Health and Human Services published in Healthy People 2010 (e.g., priority area: Heart Disease and Stroke). Choose one of the objectives listed under this priority area. What is the objective and was it met? Explain. 3. Pick any community health problem (e.g., illiteracy, teenage pregnancy, infant mortality, heart disease). a: Identify the root of the problem. For example, if you select illiteracy, is the problem that people can't read or must you dig deeper to learn what happened in the environment that resulted in "x" number of people not being able to read? Or if you select heart disease, could the actual cause be poor diet or inactivity and could the root of the problem be stress?
  19. 19. b: Identify the members of the community that should be involved in addressing this community health problem. Why did you select these members? Given your answer, will current national efforts aimed toward reducing this community health problem be successful? Explain. 4. You are the case manager for a private, nonprofit company. The center's physician referred a 58-year-old woman to you to help coordinate her medical care needs. The record reflects poor nutritional habits, a lack of physical activity, high blood sugar levels, and elevated blood pressure. The patient lives alone and is a nurse’s aide at a local nursing home. She quit school in the tenth grade. You make arrangements to visit the patient at home. Upon arrival, you notice the following: the apartment complex is run down, the apartment is roach infested, the refrigerator contains eggs, bacon, and grits and the cabinets contain products high in sodium and sugar. The patient tells you that she doesn't think that the medicine the doctor prescribed will help her feel any better and she doesn't feel confident about checking her urine for sugar. You are taking graduate courses at the local university to work toward a degree in public health. One of your professors lectured about the U.S. health care system and suggested that it encourages the medicalization of social ills. In other words, the United States views social problems as medical problems; for example, excess stress may be diagnosed as irritable bowel syndrome, headache, or fatigue. Describe what issues you as the case manager would address for the 58-year-old woman under (1) a market justice form of medical care and (2) a social justice system of care. Which one is likely to have more impact on the overall health of this woman? Explain why the United States would rather treat the manifestation of the social disease rather than the cause of the problem. Summary of Week: CHAPTER 2 Beliefs, Values, and Health PREDOMINANTAMERICAN BELIEFS RELATED TO HEALTH CARE 1. Belief in science and technology as panaceas 2. Belief in private initiatives instead of government involvement to deliver health care to mainstream America 3. Belief in individualism—responsibility for one’s own economic well-being CONSEQUENCES FOR THE HEALTHCARE DELIVERY SYSTEM 1. Emphasis on disease rather than health (medical model) Influence of the medical model:
  20. 20. • It has established the supremacy of curative medicine over the health promotion/disease prevention model (HPDP) • Definition of health as the absence of disease • Measurement of health status: use of morbidity and mortality measures (negative health conditions) • Financing for services: traditionally, better coverage for curative services than preventive services • Training of health professionals is intervention- oriented, specialist-oriented • Status of health professionals: higher status and incomes for specialists 2. Private delivery of health care in which the government plays a lesser role • Dichotomy (separation and conflict) between public health and private practice of medicine • Emphasis on individual health rather than population health 3. Achievement of health through personal means • Privately financed health insurance that is mainly employment-based • Publicly financed health insurance for the less fortunate (Medicaid and Medicare) 4. Health care has been viewed as an economic good rather than a public resource • A system based on market justice rather than social justice PERSPECTIVES ON HEALTH • The physical view—essence of the medical model. Absence of disease. Focuses on diagnosis and relief of symptoms. • The social model—incorporates the physical and social elements of health. A person’s ability to perform the expected social roles (attending school, doing housework, going to work) is interpreted as health. Seeking medical help is recommended when a person is physically unable to perform his or her social tasks. • The WHO definition—incorporates the physical, mental, and social elements of health as necessary for individual well-being. • The holistic view—includes spiritual well-being along with the other three dimensions (WHO). A person’s spirituality can have a positive impact on the individual’s overall health. This dimension has become important in several areas of healthcare delivery, such as end-of-life care and long-term care. CONCEPTS RELATED TO HEALTH Illness and disease—recognized in reference to symptoms and discomfort • Illness—self-perceived • Disease—based on professional evaluation
  21. 21. • Risk factor—an attribute that increases the likelihood (probability) that people would develop a disease or a negative health condition. A risk factor may or may not cause disease; it merely raises the probability of acquiring a disease. • Wellness—emphasizes promotion of an optimum state of well-being and prevention of disease (HPDP). Promotion of wellness is based on three factors: 1. An understanding of the health consequences of risk factors associated with host, agent, or environment. • Host—person exposed to the agent and at risk of developing a disease; genetic makeup, level of immunity, fitness, personal behaviors • Agent—a factor responsible for producing disease; bacteria/viruses, chemical agents, radiation, dietary excesses, nutritional deficiencies • Environment—set of conditions that directly or indirectly are responsible for exposing the host to the agent • Physical (sanitation, air pollution); social conditions (violence, emotional abuse, peer pressure); cultural beliefs and values; and economic factors 2. Appropriate interventions (behavior modification and therapeutic interventions) to counteract key risk factors. • Behavior modification is achieved by means of: • Education • Personal motivation • Financial incentives (tax on cigarettes) • Environmental inducements (advertising, role models) • Three levels of therapeutic interventions: • Primary prevention—interventions designed to minimize the probability of disease developing in the future (immunization, diet control, exercise programs, work safety programs) • Secondary prevention—early detection and treatment of disease (health screening, for example, blood pressure, blood sugar levels, cholesterol screening, mammography, pap smears) • Tertiary prevention—rehabilitation and prevention of further complications (restorative therapies, infection control procedures in healthcare institutions to protect against nosocomial infections) 3. Public health—application of existing scientific knowledge regarding health and disease to ensure conditions that will have the maximum positive impact on the health status of a population; quality of life; overall satisfaction with life during (processes) and following (outcomes) a person’s encounter with the healthcare system. • Process—comfort, security, independence, autonomy • Outcome—functional capacity, role fulfillment, self-perceptions of health DETERMINANTS OF HEALTH: BLUM’S MODEL In order of importance: • Environment—physical, social, cultural, and economic factors
  22. 22. • Lifestyle—behaviors, attitudes toward health • Heredity—current health and lifestyle practices are likely to impact future generations • Medical care—healthcare delivery system (access, availability of services) EQUITABLE DISTRIBUTION (AVAILABILITY) OF HEALTH CARE Distributive justice: a key concept related to access • US—demand-side rationing (price rationing). Uninsured do not have access. • National healthcare programs—supply-side rationing (planned rationing). Services are not always available when needed. Concepts of justice: United States—market justice • The idea of capitalism and free markets has been extended to health care. The role of distributing economic goods is assigned to the market. National healthcare programs—social justice • The idea of collectivism and restraining of markets has been extended to health care. The role of distributing social (collective) goods is assigned to the government. Limitations of market justice • Social justice becomes unavoidable when dealing with human problems: Housing—subsidized public housing, shelters Transportation—public transit systems Education—public schools Health care—program for underprivileged populations (Medicare, Medicaid, Indian Health Service, Veterans) • Critical care is provided to the uninsured • Human problems have broader implications for society: Homelessness, crime, substance abuse Health care—people in ill health place an economic burden on the rest of society (loss of productivity, payment for critical care), and may also place the rest of society at risk (for example, AIDS) • A robust US economy and low unemployment have not reduced the number of uninsured. Therefore, it is argued that social justice may be in the best interest of society as a whole. COMMUNITY HEALTH • Goal—to keep populations healthy by addressing a variety of issues related to the environment, lifestyles, heredity (futuristic), and medical care. For medical care, it would require universal access. TERMINOLOGY
  23. 23. • Activities of daily living (ADLs)—Measure a person’s ability to function independently, especially in reference to one’s ability to perform six basic activities: eating, bathing, dressing, toileting, maintaining continence, and getting into or out of a bed or chair. • Acute condition—Relatively severe, of short duration, and often treatable. • Agent—One of the factors of the epidemiology triangle, must be present in order for an infectious disease to occur. In other words, an infectious disease cannot occur without an agent. • Bioterrorism—Encompasses the use of chemical, biological, and nuclear agents to cause harm to relatively large civilian populations. • Cases—Refers to individuals who acquire a certain disease or condition. • Chronic condition—Less severe than an acute condition but of long and continuous duration. The patient may not fully recover. • Community health assessment—A method used for conducting broad assessments of populations at a local or state level. • Crude rates—Measures referring to the total population; they are not specific to any age groups or disease categories. • Demand-side rationing—Refers to barriers to obtaining health care faced by individuals who do not have sufficient income to pay for services or purchase health insurance. • Deontology—An individualistic principle of ethics that underscores the individual’s duty to do what is right, such as the mutual responsibilities of physicians and patients. Deontology does not place responsibility on society to provide healthcare services. The principle is used to support the concept of market justice. • Development—Refers to changes in skill and capacity to function, especially in early childhood. • The presence of disease is based on professional evaluation as opposed to self- evaluation. • Emigration—Means migration out of a defined geographic area. • Environment—One of the factors of the epidemiology triangle, is external to the host. It includes the physical, social, cultural, and economic aspects of the environment. • Epidemic—Occurs when a large number of people get a specific disease from a common source. • Fertility—The capacity of a population to reproduce. • Health care—Refers to the treatment of illness and the maintenance of health. • Health risk appraisal—Refers to the evaluation of risk factors and their health consequences for individuals. Health risk appraisal is an important aspect of health promotion and disease prevention because it can be instrumental in developing avenues for motivating individuals to alter their behaviors to more healthful patterns. • Holistic health—Emphasizes the well-being of every aspect of what makes a person whole and complete. • Holistic medicine—Seeks to treat the individual as a whole person. • A host—One of the factors of the epidemiology triangle, is an organism, generally a human, who receives the agent. The host is the organism that becomes sick. • Iatrogenic illnesses (or injuries)—Caused by the process of health care.
  24. 24. • Illness—Recognized by means of a person’s own perceptions and an evaluation of how he or she feels. For example, an individual may feel pain, discomfort, weakness, depression, or anxiety, but a disease may or may not be present. • Immigration—Means migration to a defined geographic area. • Incidence—Counts the number of new cases occurring in the population at risk within a certain time period, such as a month or a year. • Instrumental activities of daily living (IADLs)—Used in reference to a person’s ability to perform activities that are necessary for living independently in the community, such as preparing meals, shopping for routine items, managing money, and housekeeping. • Life expectancy—The prediction of how long a person will live. • Market justice—Ascribes the fair distribution of health care to the market forces in a free economy. Medical care and its benefits are distributed on the basis of people’s willingness and ability to pay. • The medical model of healthcare delivery presupposes the existence of sickness. In other words, health care is delivered only when a person is sick. The model emphasizes diagnosis and treatment of disease as opposed to health promotion and disease prevention. • Migration—Refers to the geographic movement of populations between defined geographic units, and involves a permanent change of residence. • Morbidity—Means disease or disability. • Mortality—The term used in the measurement of death rates. • Natality—Refers to the birth rate. • Planned rationing—See supply-side rationing. • The population at risk—Include all the people in the same community or population group who are susceptible to acquiring a disease or a negative health condition. • Prevalence—Measures the total number of cases (of death, disability, or disease) at a specific point in time in the population at risk. • Primary prevention—Refers to actions designed to reduce the odds that a disease will subsequently develop. Its objective is to restrain the development of a disease or negative health condition before it occurs. Smoking cessation, prenatal care, hand washing, and refrigeration of foods are examples of primary prevention. • Public health—Deals with broad societal concerns about ensuring conditions that promote optimum health for society as a whole by influencing the social, economic, political, and medical care factors that affect health and illness. The objective of public health is to prevent disease, prolong life, and promote health through organized community effort. • Quality of life—Refers to overall satisfaction with life during and following a person’s encounter with the health delivery system. Some of the life domains germane to quality of life are comfort factors, security, degree of independence, decision-making autonomy, and attention to personal preferences. • Risk factors—Attributes that increase the likelihood of developing a particular disease or negative health condition at some time in the future. Risk factors can be traced to the agent, the host, and/or the environment. • Secondary prevention—Refers to early diagnosis and treatment of disease. Health screening plays a key role in secondary prevention. The objective is to block the progression of disease.
  25. 25. • Social contacts—Evaluated in terms of the number of social contacts or social activities a person engages in within a specified period of time. Examples are visits with friends and relatives, and attendance at social events, such as conferences, picnics, or other outings. • Social justice—Regards health care as a social good that should be collectively financed through general taxes, and made available to all citizens regardless of the individual’s ability to pay. • Social resources—Refer to social contacts that can be relied upon for support, such as family, relatives, friends, neighbors, and members of a religious congregation. They are indicative of adequacy of social relationships. • A sub-acute condition—Between acute and chronic, but with some acute features. • Supply-side rationing—Also called planned rationing because the government, faced with limited resources, makes deliberate attempts, often referred to as “health planning,” to limit the availability of healthcare services, particularly those beyond the basic level of care. • Tertiary prevention—Refers to rehabilitative activities and the monitoring of treatment regimens to prevent further complications. • Utilitarianism—A principle of ethics that emphasizes happiness and welfare for the masses, while ignoring the individual. Its main motto is “the greatest good for the greatest number of people.” • Utilization—Refers to the extent to which healthcare services are used. • The wellness model—Views health as a positive concept. The model emphasizes efforts and programs geared toward prevention of disease and maintenance of an optimum state of well-being. END OF CHAPTER 2 SUMMARY REVIEW AND DISCUSSION QUESTIONS End Week 2 WEEK 3 Start Week 3 Objectives: Chapter 3 1. Discover the history that has shaped the U.S. Health Care Delivery System. 2. Evaluate why the system has been resistant to national health insurance reforms. 3. Explore developments and key forces that help shape the delivery of health services in the U.S. Reading Assignments: a) Chapter 3, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’)
  26. 26. c) Read Ten Great Achievements of Public Health (webpage html file) found in the Web Course. Lecture Assignments: a) View the Course Overview and Assignments Presentation including: i. Thought Worksheet Assignment Presentation ii. Cost Quality Access Model Assistant Presentation b) View this Week’s Lecture c) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) There are no quizzes this week Thought Worksheet Assignment: a) Thought Worksheet # 1 is due this week. Universal Health Coverage is the topic for this assignment. Email the completed assignment to your instructor. b) Your Thought Worksheet Assignment topic for you to analyze is: Universal Healthcare Coverage in the United States. Review Questions (based on your points selections): a) Complete/Answer Review Questions for Chapter 3 and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for Chapter 3 and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 34 points) 1. Why did the professionalization of medicine start later in the United States than in some Western European nations? (Comprehension: 2 points) 2. Why did medicine have a domestic rather than a professional character in the pre-industrial era? How did urbanization change that? (Comprehension: 2 points) 3. Which factors explain why the demand for the services of a professional physician was inadequate in the pre-industrial era? How did scientific medicine and technology change that? (Comprehension: 2 points) 4. How did the emergence of general hospitals strengthen the professional sovereignty of physicians? (Application: 3 points)
  27. 27. 5. Discuss the relationship of dependency within the context of the medical profession’s cultural and legitimized authority. What role did medical education reform play in galvanizing professional authority? (Synthesis: 4 points) 6. How did the organized medical profession manage to remain free of control by business firms, insurance companies, and hospitals until the latter part of the 20th century? (Comprehension: 2 points) 7. Discuss the key factors that were instrumental in the growth of voluntary health insurance. (Comprehension: 2 points) 8. Discuss, with particular reference to the roles of (a) organized medicine, (b) the middle class, and (c) American beliefs and values, why reform efforts to bring in national health insurance have been unsuccessful in the United States. (Synthesis: 4 points) 9. Which particular factors that earlier may have been somewhat weak in bringing about national health insurance later led to the passage of Medicare and Medicaid? (Comprehension: 2 points) 10. Discuss the government’s role in the delivery and financing of health care with specific reference to the dichotomy between public health and private medicine. (Application: 3 points) 11. Discuss why the structure of medical care delivery in the United States did not develop around a nucleus of primary care. (Comprehension: 2 points) 12. Explain how contract practice and prepaid group practice were the prototypes of today’s managed care plans. (Comprehension: 2 points) 13. Discuss the most notable forces that are continuing to shape the healthcare delivery system. (Synthesis: 4 points) ONLINE CHAT & DISCUSSION BOARD QUESTIONS 1. How did the emergence of general hospitals strengthen the professional sovereignty of physicians? 2. How did medical education reform change the profession of medicine? 3. List and describe two federal or state regulatory standards (e.g., laws) that apply to the private sector. What do they intend to control and are they meeting their objectives?
  28. 28. 4. You are a lead policy analyst for the Centers for Medicare and Medicaid Services (CMS; formerly known as the Health Care Financing Administration [HCFA]). A member of the U.S. Senate has contacted your boss, the head of CMS, hoping to better understand the benefits of a national health insurance (NHI) program. The senator explained that he has heard all kinds of reasons why an NHI program couldn't work in the United States and wants to get the real scoop. Your boss meets with you to discuss how best to approach the request of the senator. It is agreed that you must first research why previous proposals favoring NHI have failed in the United States. During your research you partially conclude the reason for failure is the American value system, which is based on individualism, little government interference, and free market principles. What do you also learn about past efforts? Given all your research, would Americans today support a national form of health insurance? Explain. What would it take to overcome or address these past failures? Summary of Week: CHAPTER 3 The Evolution of Health Services in the United States Professionalization of medicine started later in the United States than Western Europe. Reasons include the following: 1. Medical science, experimental research, and medical education developed later in the United States 2. American cultural attitudes—self-reliance, home remedies, and familial care PREINDUSTRIAL ERA—1700S TO LATE 1800S • Characterized by medicine as a domestic rather than a professional institution • Unorganized trade—free entry, competition, training through apprenticeship • Primitive medical procedures—bleeding, use of emetics and purgatives, purging with enemas • Missing institutional core—institutions fulfilled a charity and welfare rather than a healthcare function • Almshouses (poorhouses) and pesthouses; dispensaries (outpatient) used for apprenticeship and experimentation; a few voluntary hospitals (local charity rather than tax support) • Low demand for medical services—family-based care, self-reliance; physician services were expensive, mainly due to opportunity costs of travel; no health insurance; private fee-for-service; limited benefits from medical treatment • Disorganized medical education—schools started by physicians, no admission requirements, general studies, little training in biological sciences POSTINDUSTRIAL ERA—LATE 1800S TO MID 1900S • Characterized by professional sovereignty
  29. 29. • Urbanization—proximity (reduced opportunity costs), change in the family’s social structure • Science and technology—bacteriology, antiseptic techniques, anesthesia, diagnostic equipment, new drugs • Medical practice required science-based education, skills, and expertise • Legitimacy and acceptance of professional judgment (cultural authority) • Increased demand for professional services • Institutionalization—modern hospital provided an institutional core • Physicians started many of the early hospitals with financial support from local philanthropists • Hospitals had to depend on physicians to admit patients and keep the beds filled • Hospitals became indispensable for medical practice due to advances in anesthesia and surgery, which created a demand for hospital services • Dependency—created by: Cultural authority of physicians 1. Patients in a dependent role/sick role (Chapter 2)—requires patients to seek medical help when declared sick. It also expects them to resume their regular social roles when declared well, but the latter often requires a physician’s certification. 2. Insurers became dependent on physicians’ judgment. 3. Need for hospital services for critical illness or surgery. • Professional cohesiveness—specialization, educational reform, and professionalization led to the need for patient referrals between physicians, sharing of ideas, and formal organization. American Medical Association (organized medicine)— control over medical practice, licensing, and education; for example, licensing was contingent on graduation from AMA-approved schools. Organized resistance to any interference with the private practice of medicine, such as contract practice, salaried employment, public health. GROWTH OF PUBLIC HEALTH Urbanization increased concerns about protecting the health of populations. Most states created public health departments by the start of the 20th century. Main functions: • Promotion of sanitation • Control of communicable disease • Regulation of food and water • Operation of state laboratories • Health education • Maintenance of vital statistics • Limited medical care delivery: • Child immunizations • Maternity and child welfare • School health screening • Family planning • Substance abuse and mental health
  30. 30. Organized medicine kept private practice separated from public health for fear that it would invite government intervention and control. The development of public health can be credited with the remarkable drop in mortality from infectious diseases, and the dramatic rise in life expectancy. Now, chronic illnesses have become the leading cause of illness, disability, and death in the United States and other developed nations. RISE OF PRIVATE HEALTH INSURANCE Three forces led to the need for health insurance in America. 1. Technological—advanced treatments that were desirable but expensive 2. Social—desire of medical treatments, the “sick role” 3. Economic—risk of catastrophic loss Other key developments: 1. The Great Depression provided the impetus for private health insurance. People as well as institutions needed economic protection. The Baylor plan (1929) introduced the concept of hospital insurance, a prepaid plan based on capitation. This led to the creation of Blue Cross. California Medical Association started the first Blue Shield plan. 2. Wage freezes during World War II—insurance benefits became important in union negotiations. 3. Tax-free status of health insurance benefits made health insurance a more desirable substitute for cash wages. NATIONAL HEALTH INSURANCE In Europe, main reasons: • To pacify labor unrest that threatened political stability • To ensure fitness of armed servicemen • To improve economic productivity • Primary motivation was not grounded in ensuring the health and well-being of all citizens In the United States • 1914—Workers’ compensation: a social benefit • Initially covered loss of wages due to job-related illness and injury • Later, medical expenses and death benefits were added • 1917—The American Association of Labor Legislation attempted to expand its social agenda by advocating national health insurance. • 1935—Franklin Roosevelt era, New Deal (Social Security passed) • 1940s—Truman became the first president to use his office to advocate national health insurance. Private health insurance was expanding at this time. • 1992—Clinton and Bush propose health plans during presidential election • Wofford’s victory in Pennsylvania United States Senate election • Rising costs of health care were widely viewed as a major concern • Polls showed significant fear of loss of coverage, problems with receiving services
  31. 31. Main reasons why proposals favoring NHI have been defeated in the United States (differences between Europe and the United States) 1. No political threats 2. Private infrastructure (physicians, hospitals) 3. Sovereignty of the medical profession (AMA opposition) 4. Opposition from insurance industry, pharmaceutical industry, business (costs) 5. Opposition from labor unions (government was viewed as a usurper of their benefactor’s role) 6. Beliefs and values of the American middle class: Market justice, Individualism and self-determination, Distrust of government, Reliance on the private sector to address social concerns 7. Tax aversion PUBLIC HEALTH INSURANCE IN THE UNITED STATES • Private health insurance for the middle-class • Tax supported programs for the elderly and poor were successful because they were viewed as charity: Rising costs of health care that these groups could not generally afford. Poorer health status compared to general population Greater incidence and prevalence of disease Greater need to utilize healthcare services • Growing size of the elderly population gave them greater political clout • Social Security Amendments of 1965 produced Medicare and Medicaid MAIN EFFECTS OF MEDICARE AND MEDICAID • Opened access for a significant proportion of the uninsured population • Significantly contributed to the growth of healthcare expenditures • Monitoring and regulation of healthcare facilities became linked to public financing • Medicare—Title 18 of the Social Security Amendment (covers the elderly and disabled), federal program • Part A—hospital care, limited nursing home care in a skilled nursing facility • Part B—government subsidized insurance for outpatient services • Medicaid—Title 19 (covers the poor, but eligibility is based on means test), federal/state program MAIN FEATURES OF THE TWO PROGRAMS Medicare—Initially created for the elderly (later disabled, and end-stage renal disease were added), federal program, allowed balance billing (higher acceptability with providers). Medicaid—Created for the poor, federal/state program, administered by each state, no balance billing (unpopular with providers)
  32. 32. PROTOTYPES OF MANAGED CARE Contract practice • Direct contracting with industry in remote areas, use of salary or capitation • Hospital associations (in Oregon) Group practice • Consolidation of various types of practice, economic efficiency Prepaid group plans • Enrolled population, comprehensive services, capitated fee RECENT EVOLUTIONS • Cost escalations, rather than universal access, represent people’s primary concern. • Government has played the primary role in cost containment, but its role in managing the entire system is viewed with skepticism. • Changes in financial incentives have shifted health services delivery from inpatient to outpatient. Hospitals have diversified into post-acute extended care and home health. Particularly in long-term care, there has been a shift from institutionalization to community-based services. • Growing use of self-care and alternative remedies. • Outbreaks of disease caused by new viruses such as ebola, West Nile, and corona (associated with SARS— severe acute respiratory syndrome). • Bioterrorism has created a new awakening for the role of public health in protecting people against the threats of germs, chemicals, and other agents used as weapons of mass destruction. • An aging population forebodes a dramatic rise in chronic health conditions, with staggering costs associated with disability and long-term care services. • Quality of medical care and use of standardized treatment protocols are receiving ongoing emphasis. • The Internet has revolutionized medical information. • Diversity and minority health issues are receiving greater attention. • Growth of managed care during the 1990s was successful in containing healthcare costs, but spending has once again started to escalate. • Integrated delivery organizations evolved in response to managed care. • Physicians continue to vie for autonomy, as seen in some initial efforts to unionize, and to separate from hospitals to form independent specialty clinics. • In the maze of organizational dominance, the consumer has been practically stripped of any market power. TERMINOLOGY • Almshouse—Also a poorhouse, was an unspecialized institution existing during the 18th and mid-19th centuries that mainly served general welfare functions, essentially providing shelter to the homeless, the insane, the elderly, orphans, and the sick who had no family to care for them.
  33. 33. • Balance bill—The practice of billing the patient for the balance remaining after insurance has paid its share of the total charges. • Capitation—A payment mechanism in which all healthcare services are included under one set fee per covered individual. The fee is generally paid per month, hence it is also referred to as per-member-per-month (PMPM). The fee covers all services an enrollee may need during the entire year. • Cost shifting—Occurs when losses experienced in one area of healthcare delivery are made up by charging more in another area. For example, shortfalls in revenues from providing charity care are made up by charging more to private payers. • Cross-subsidization—See cost shifting. • Cultural authority—Refers to the general acceptance of professional judgment as valid. Physicians’ cultural authority is reflected in the reliance placed on their evaluation of signs and symptoms, diagnosis of disease, and suggested prognosis. • Fee-for-service—The practice of billing separately for each individual type of service performed. • Gatekeeping—Requires patients to initially make contact with a generalist who provides basic and routine care, evaluates the need for specialized services, and makes referrals to specialized care if it is determined to be appropriate. • Means test—Income-based determination of eligibility to receive healthcare services or to participate in a program such as Medicaid. • Medicaid—The program that provides health care to the poor through federal matching funds provided to the states based on each state’s financial needs. • Medicare—The publicly financed health insurance program for the elderly and certain disabled persons. • Organized medicine—Refers to the concerted activities of physicians through the American Medical Association (AMA). The term has been used to distinguish collective efforts from the uncoordinated actions of individual physicians competing in the marketplace. • Part A of Medicare—Provides coverage for hospital care and limited nursing home care. • Part B of Medicare—Government-subsidized voluntary insurance for physician services and outpatient services. • Pesthouse—Operated by local governments during the 18th and mid-19th centuries to quarantine people who contracted a contagious disease such as cholera, smallpox, or typhoid. The primary function of a pesthouse was to protect the community from the spread of contagious disease; medical care was only secondary. • Primary care—The delivery of routine and basic care in which the primary care physician also ensures the continuity, coordination, and appropriateness of medical services received by a patient. • Title XVIII—Or more precisely, Title XVIII (18) of the Social Security Amendment of 1965 refers to the Medicare program. • Title XIX—Or more precisely, Title XIX (19) of the Social Security Amendment of 1965 refers to the Medicaid program.
  34. 34. End Week 3 WEEK 4 Start Week 4 Objectives: Chapter 4 1. To recognize the different types of health service professionals. 2. To differentiate between primary and specialty care, and the causes for imbalance between the two in the U.S. 3. Discuss maldistribution in the physician labor force. 4. Develop a potential plan to help overcome the physician imbalance and maldistribution. 5. To understand the role of non physician providers. 6. To identify Allied Health professionals and their roles. 7. The discuss the functions and qualifications of health service administrators amid the various professional settings of the career. Reading Assignments: a) Chapter 4, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) c) Study the file “Learning Map Orchestrating Great Care” found in the web course and think about what it takes to lead healthcare professionals and manage healthcare resources. Lecture Assignments: a) View this Week’s Lecture b) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) Complete Quiz 1 on the WebCT Course Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. b) Your next Thought Worksheet Assignment is due in week 6 and the topic for you to analyze is: Increased Utilization of Customized Medical Products (such as Pharmaceuticals, Implants, Prosthetics, etc…).
  35. 35. Review Questions (based on your points selections): a) Complete/Answer Review Questions for this week’s chapter and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for this week’s chapter and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 19 points) 1. Describe the major types of health services professionals (physicians, nurses, dentists, pharmacists, physician assistants, nurse practitioners, certified nurse midwives), including their roles, training, practice requirements, and practice settings. (Comprehension: 2 points) 2. What factors are associated with the development of health services professionals in the United States? (Comprehension: 2 points) 3. What are the major distinctions between primary care and specialty care? (Comprehension: 2 points) 4. Why is there a geographic maldistribution of the physician labor force in the United States? (Synthesis: 4 points) 5. Why is there an imbalance between primary care and specialty care in the United States? (Comprehension: 2 points) 6. What measures have been or can be employed to overcome problems related to physician maldistribution and imbalance? (Application: 3 points) 7. Who are nonphysician primary care providers? What are their roles in the delivery of health care? (Comprehension: 2 points) 8. In general, who are allied health professionals? What general role do they play in the delivery of health services? (Knowledge: 1 point) 9. Provide a brief description of the roles and responsibilities of health services administrators. (Knowledge: 1 point) ONLINE CHAT & DISCUSSION BOARD QUESTIONS
  36. 36. 1. What settings and challenges (situations for management and leadership) are possible for entry to middle level of health services administrators? 2. A primary care office located in a predominately African-American urban community provides a full range of health care services including obstetrics, pediatrics, and geriatrics. The clinic is staffed with international physicians and licensed practical nurses (LPNs). There continues to be reports that large numbers of people in your community are not accessing needed services and the health of the community is worse than in neighboring urban communities. Describe how the use of non-physician health care practitioners (certified nurse practitioner, physician assistant, or certified nurse midwife) could affect access, cost, and quality in this community. Summary of Week: CHAPTER 4 Health Services Professionals NEGATIVE CONSEQUENCES OF SPECIALTY MALDISTRIBUTION 1. High volume of intensive, expensive, and invasive medical services (overuse of medical services) with increased healthcare spending. Society receives lower value for the healthcare dollars spent. 2. Increased demand for specialist care. 3. Specialist services have less impact in improving overall health status. 4. Problems with access to care by the underserved. OTHER DOCTORAL-LEVEL PROFESSIONALS Optometrist (OD)—vision correction Psychologist (PhD)—mental health counseling and psychotherapy Podiatrist (DPM)—diseases and deformities of the feet Chiropractor (DC)—literally, hand manipulation. It is rooted in the belief that the health of the spinal column and nervous system is central to well-being. Studies show that chiropractic is an effective form of treatment for back pain. NURSES • Constitute the largest group of healthcare professionals. • Two basic levels of licensed nurses: 1. RN—three avenues of RN education/preparation: Associate degree (ASN, Associate of Science in Nursing, 2 years), Diploma (hospital program, generally 3 years), and Bachelor’s degree (BSN, 4 years)
  37. 37. 2. LPN (LVN)—1 to 2 years at a community college Impact of decline in hospital stay: Growth of other settings such as home health and nursing homes, which has led to a growth in nursing employment in these settings. Other growth areas for RNs: • Case management • Utilization review • Quality assurance • Prevention counseling • Training of other nurses • Primary care Advanced practice nurses (APNs): • Have attained education and training beyond the RN level. • Four main categories: 1. Clinical nurse specialists—Work in hospitals (vs. home health, clinics, or nursing homes). Specialize in fields such as cardiac care, oncology, neonatal care, psychiatric care. 2. Certified Registered Nurse Anesthetists—Trained to manage anesthesia during surgery. 3. Nurse Practitioners—Trained to provide primary care services, often ndependent of physicians. 4. Certified Nurse Midwives—Deliver babies and manage the care of mothers and newborns before, during, and after delivery. NONPHYSICIAN PRACTITIONERS (NPPS) NPPs practice in areas similar to those in which physicians practice, but they do not have MD or DO degrees, and they mainly practice in primary care settings. Their practice results in improved access to primary care. Care rendered is often equivalent in quality to that provided by physicians, and is cost effective. Patients generally express a greater degree of satisfaction with care from NPPs, as compared to care received from physicians, due to better communication with the NPPs and the fact that NPPs generally spend more time with patients than do physicians. • Physician assistants (PAs)—Most graduate from bachelor’s degree programs. Work in a dependent relationship under a supervising physician (onsite or off-site). • Nurse practitioners (NPs)—Often have master’s degree plus advanced clinical training. They can practice independently of physicians. In most states, NPs can receive direct Medicaid and Medicare payments for their services. • Certified nurse midwives (CNMs)—Can substitute for obstetrician/gynecologist. Handle routine pregnancies as competently or better than physicians do. ALLIED HEALTH PROFESSIONALS Need created by the growth of technology and specialization in medicine. They function in roles that are complementary to those of physicians and nurses. Two main categories:
  38. 38. 1. Technologists and therapists—PTs, OTs, Speech therapists, Dieticians, Medical technologists, etc. 2. Technicians and assistants—PT and OT assistants, laboratory technicians, emergency medical technicians, dental hygienists, etc. HEALTH SERVICES ADMINISTRATORS • Organize, coordinate, and manage the delivery of healthcare services. • Provide leadership, direction, and strategic planning in health services organizations. • Challenges faced: • changes in financing and reimbursement • impact of new public policies • competition • pressures to provide uncompensated care, particularly by non-profit organizations • accountability for quality • integrity, ethics, and public’s trust TERMINOLOGY • Advanced practice nurses (APNs)—Nurses who have education and clinical training beyond that required for an RN. The four areas of specialization in nursing include clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), nurse practitioner (NP), and certified nurse midwife (CNM). NPs and CNMs are also categorized as nonphysician practitioners. • Allied health—Includes a large number of health-related areas, its main function being to complement the work of physicians and other healthcare providers. Examples include anesthesiologist assistants, cardiovascular technologists, emergency medical technicians/ paramedics, medical assistants, medical laboratory technicians, medical record administrators, medical record technicians, occupational therapists, radiographers, respiratory therapists and technicians, specialists in blood bank technology, surgeon’s assistants, and surgical technologists. • Certified nurse midwives (CNMs)—Registered nurses with additional training from a nurse-midwifery program in areas such as maternal and fetal procedures, maternity and child nursing, and patient assessment. • Chiropractors—Provide treatment to patients through chiropractic (done by hand) manipulation, physiotherapy, and dietary counseling. They typically help patients with neurological, muscular, and vascular disturbances. Chiropractic is based on the belief that the body is a self-healing organism. • Comorbidity—Refers to the condition when patients have multiple health problems. • Dental assistants—Work for dentists in the preparation, examination, and treatment of patients. While dental assistants do not have to be licensed to work, there are formal training programs available that offer a certificate or diploma. • Dental hygienists—Provide preventive dental care, including cleaning teeth and educating patients on proper dental hygiene. Dental hygienists must be licensed to practice.
  39. 39. • Dentists—The major providers of dental care and must be licensed to practice. Their major roles are to diagnose and treat dental problems related to the teeth, gums, and tissues of the mouth. Eight specialty areas are recognized by the American Dental Association: orthodontists (straightening teeth), oral and maxillo facial surgeons (operating on the mouth and jaws), pediatric dentistry (dentists for children), periodontics (treating gums), prosthodontics (making artificial teeth or dentures), endodontics (root canal therapy), public health dentistry (community dental health), and oral pathology (diseases of the mouth). • Generalists—Physicians trained in family medicine/general practice, general internal medicine, and general pediatrics in the United States. They are considered primary care providers. • Licensed practical nurses (LPNs)—Called licensed vocational nurses (LVNs) in some states, care for patients under the direction of physicians and registered nurses. They must complete a state-approved program in practical nursing and a national written eamination. • Maldistribution—Refers to either a surplus or a shortage of the type of health providers (typically physicians) needed to maintain the health status of a given population at an optimum level. Maldistribution can occur both geographically and by specialty. • Nonphysician practitioners (NPPs)—Providers who practice in many areas similar to those in which physicians practice, but they do not possess a doctoral degree. NPPs are sometimes called midlevel practitioners because they receive less advanced training than physicians do, but more training than registered nurses. They are also referred to as physician extenders because in the delivery of primary care they can, in many instances, substitute for physicians. NPPs typically include physician assistants (PAs), nurse practitioners (NPs),and certified nurse midwives (CNMs). • Nurse practitioners—Advanced practice nurses (APNs) who have completed a program of study leading to competence as RNs in an expanded role. NPs are trained to practice independently of physicians, and can often substitute for primary care physicians. • Occupational therapists (OTs)—Help people of all ages improve their ability to perform tasks in their daily living and working environments. They work with individuals who have conditions that are mentally, physically, developmentally, or emotionally disabling. • Optometrists—Provide vision care, including examination, diagnosis, and correction of vision problems. They must be licensed to practice. • Osteopathic medicine—Emphasizes the musculoskeletal system of the body, such as correction of the joints or tissues, and stresses diet and the environment as factors that might influence natural resistance. • Pharmaceutical care—Refers to a mode of pharmacy practice in which the pharmacist takes an active role on behalf of patients by assisting the prescribers in appropriate drug choices, effecting distribution of medications to patients, and assuming direct responsibilities collaboratively with other healthcare professionals and with patients to achieve the desired therapeutic outcomes. • Pharmacists—Dispense medicines prescribed by physicians, dentists, and podiatrists, and provide consultation on the proper selection and use of medicines. All states require a license to practice pharmacy. The role of pharmacists has expanded over the last two
  40. 40. decades to include drug product education and serving as experts on specific drugs, drug interactions, and generic drug substitution. • Physical therapists (PTs)—Provide care for patients with movement dysfunction. • Physician assistants (PAs)—Work in a dependent relationship with a supervising physician to provide comprehensive care. PAs assist physicians in the provision of care to patients. The major services provided by PAs include evaluation, monitoring, diagnostics, therapeutics, counseling, and referral. • Physician extenders—See nonphysician practitioners. • Podiatrists—Treat patients with diseases or deformities of the feet, including performing surgical operations, prescribing medications and corrective devices, and administering physiotherapy. They must be licensed to practice. • Primary care—First-contact care or the portal to the healthcare system. Primary care focuses on the person as a whole. It seeks to balance the multiple requirements for which a patient’s condition may call and refers patients to appropriate specialty care when needed. Primary care should incorporate continuity, comprehensiveness, and coordination with other levels of care. • Psychologists—Non-physicians who are trained to provide mental health care using counseling and psychotherapy. They must be licensed or certified to practice. • Residency—Graduate medical education in a specialty that takes the form of paid on- the-job training, usually in a hospital. • Registered nurses (RNs)—The major caregivers of sick and injured patients, serving their physical, mental, and emotional needs. All states require nurses to be licensed in order to practice. An RN must complete an associate’s degree (ADN), a diploma program, or a bachelor’s degree (BSN). • Specialists—Physicians who also hold certification in a specialty area. Specialty certification requires additional years of advanced residency training followed by several years of practice in the specialty. A specialty board examination is often required as the final step for becoming a board-certified specialist. Common specialties include anesthesiology, cardiology, dermatology, family medicine, internal medicine, neurology, obstetrics and gynecology, ophthalmology, pathology, pediatrics, psychiatry, radiology, and surgery. • Specialty care—Tends to be limited to illness episodes, the organ system, or the disease process involved. Specialty care, if needed, generally follows primary care. End Week 4 WEEK 5 Start Week 5 Objectives: Chapter 5 1) Understand the broad term and use of technology in health related environments 2) Discuss the categories of technology in health and medicine

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