Health Care Systems
This article examines the structural components of the health care system in the United States. The interactions among the components, specifically health care providers, patients, and payors are presented. Strengths and weaknesses of current health care delivery and finance mechanisms are described in terms of impact on health care expenditures and health status. The article concludes with a brief discussion of why the U.S. health care system is in need of reform.
Keywords Allied Health; Health Care Finance; Health Insurance; Hospital; Medicaid; Medicare; Physician
Health Care Management: Health Care Systems
A health care system is an organized collection of individuals and organizations that provide for the access, financing, and delivery of medical services to individuals. As a general definition, a system is a logical "set of interdependent parts organized with a sense of logic and consistency" (Southby, 2004). Yet, there are those who argue that the health care system in the United States is both illogical and inconsistent. The U.S. spends more on health care (as measured by percent of GDP) with worse health outcomes than many other developed nations (Southby, 2004). Health care costs impact both public and private sectors and have enormous implications for global competitiveness, employee productivity, and economic stability. Health care reform is a dominant issue on the public discussion agenda but the formation of realistic or meaningful approaches for reform does not yet have a place on the decision agenda in both the federal and state governments.
Structural Components of the U.S. Health Care System
The structural components of a health care system refer to the methods and means of health care delivery and access: the who, the what and the where of providing health care to individuals and groups. In modern societies, health care is traditionally provided by a physician trained in the medical sciences. As a society, we grant to physicians the technical, legal, and cultural authority to give patients information and render treatment for their medical conditions. This has not always been the case. Up until the late nineteenth century, most medical care was provided within families. Physician services were a last resort. As research began to provide physicians with proven treatments (especially through the understanding of disease, the importance of asepsis, and the development of antibiotics), medical knowledge became the exclusive domain of physicians. This position was reinforced through standardized training and the rise of physicians as a sovereign profession (Starr, 1982).
As specialization emerged within medical practice, conflict between general practitioners and specialists emerged as specialists sought to maintain exclusivity in certain types of practice. Ophthalmology, endocrinology, and neurology are a few examples of specialization. By controlling access to specialty training through governing boards, e.g. the American Board of Ophthalmology, specialists effectively restricted general practitioners from taking on patients with specific types of conditions (Starr, 1982). As a result, a hierarchy within the practice of medicine arose, with general practitioners typically viewed as lower in status, and subsequently lacking the ability to charge and collect higher fees. The term "general practitioner" is not in wide use today. Those physicians who provide overall broad-based medical care are referred to as "primary care" physicians. Family practice, general internal medicine, pediatrics, and obstetrics/gynecology are considered primary care practices. Examples of specialty and subspecialty practices are neurology, endocrinology, dermatology, and ophthalmology, along with the range of surgical specialties such as neurosurgery, orthopedic surgery, etc.
Other providers that are key to the delivery of medical care are nurses and the professionals that are sometimes referred to as physician extenders. This latter group includes nurse practitioners (nurses with advanced medical training) and physician assistants. In addition, there is a vast spectrum of technicians and therapists who practice under the aegis of particular physician specialists. These professionals, known as allied health providers, are trained in specific technologies that provide physicians with the diagnostic and therapeutic data required in the treatment of specific medical conditions. Examples are the imaging technologies (x-ray, computerized tomography (CAT scans), mammography, and magnetic resonance imaging (MRI)), the biologic and biochemical diagnostics (blood chemistry, urinalysis, pathology, etc.), and the rehabilitative therapies (physical therapy, respiratory therapy, occupational therapy, and others).
Outside the mainstream of traditional health care providers are those who practice alternative forms of medicine. Examples of these are chiropractors, naturopaths, and practitioners of alternative treatments such as acupuncture, nutritional therapists, and herbalists.
Outside the scope of primary care and specialty care is the system of mental health care. Within mental health care is a corresponding network of providers that range from the specialty of psychiatry to non-MD providers such as psychologists, social workers, and addiction counselors and therapists, to name a few.
Categories of Delivery
The second component of access to care — the what — addresses the categories of health care delivery. In the United States, the categories are acute care, long-term care, and mental health care. Acute care refers to any medical condition that is diagnosed and successfully cured. Examples include a broken bone, an intestinal disorder, a fungal rash, and other more or less complicated diseases. Long-term care refers to a condition that can be diagnosed but not necessarily cured and must be treated by managing the symptoms or effects of the disease. Examples include arthritis, diabetes, some forms of cancer, etc. As the population ages, medical care becomes more the practice of long-term care and the management of multiple and overlapping conditions. The emphasis in long-term care is not to cure but to maintain function; that is, to provide treatments and management strategies to help patients cope with the daily management of their disease or condition and enable them to live as full and independent a life as possible. For example, a patient with diabetes must learn to follow a specific diet, monitor their blood sugar levels daily, and watch for changes in their vision and circulatory problems, especially those that are manifested in the foot.
Medical Care Facilities
The third component of access and delivery — the where — refers to the physical facilities where medical care is provided. Just as the nature of medicine has changed over time, so have the facilities where medical care is delivered. For centuries, physicians diagnosed and treated their patients in the patient's home. The home visit, once the hallmark of medical care, now has all but vanished. The primary facilities for the delivery of medical care are the hospital and the physician's office. Just as the practice of medicine was transformed through the introduction of science and technology, hospitals were also transformed by increasing advances in medical care. Evolving from institutions of charity care and warehouses for the poor, the aged, and the infirm, hospitals today are facilities tailored to the delivery of modern scientific and technological treatments. Physician offices similarly have evolved from the one- or two-room office of the solo...
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