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NRSE 6002
 Fall 2012
   High technology
   Sophisticated institutions
   Leading edge research
   High level training for health professionals
•   Lack of standardized payment system
•   Unequal access for citizens
•    No central coordinating agency
•   Wide array of service settings that are not
    inter-connected
•   Few universal quality standards
•   Greater proportion of total economic output
•   Poorer outcomes than many developed
    countries
SUSHCS
•   10 million people employed in health care
•   664,000 MDs
•   37,000 Dos
•   2 million nurses
•   162,000 dentists
•   200,000 pharmacists
•   700,000 health care administrators
•   500,000 rehab therapists
   6,200 hospitals
   16,700 nursing homes
   5,400 mental health facilities
   13,500 home health agencies
   1,200 FQHCs
   3,400 RHCs
   142 MD and DO schools
   54 dental schools
   80 pharmacy schools
   1,500 nursing schools (all levels)
   1,000 commercial health insurance
    companies
   70 Blue Cross/Blue Shield plans
   750 health maintenance organizations
   1,050 preferred provider organizations
   Self-insured employers
   Federal government
   State governments
What’s our his o   ?
   Women cared for the sick
   Healers, herbalists, midwives
   Passed traditions and knowledge from
    generation to generation
   Care centered in the home
   Care given by family and community
    members
   Physicians were rising in Europe, but not in
    America
   Until 1800s, training was by apprenticeship
   Basic science research was centered in Europe
   American physicians focused on applied
    medicine – “practical” techniques

                                      Medical
                                      Journal
   In 1800, 4 medical schools in US
   In 1850, there were 42
   AMA formed in 1847
   Reform of medical education began in the
    1870’s and turned radically in 1910
•   Urbanization
•   Science and technology
•   Rise of hospitals
•   Cultural authority
•   Maintenance of independent (non-employee)
    status through organization and cohesiveness
•   Licensing
•   Educational reform
   Nursing arose from healing and religious
    traditions
   Development of nursing entwined with status
    of women over the centuries
   Nightingale ushered in era of “modern” nurse
    in 1860
   NC first state to license “registered nurses” in
    1903
   State practice acts formalized profession
   Apprenticeship
   Hospital schools
   Goldmark Report (1923) found nursing
    education inadequate in hospital programs
   Shift to college and university education
    initiated in 1893 and continues today
   Let’s discuss!
   Earliest hospitals in US were almshouses or
    were to isolate people with infectious disease
    or mental illness
   General hospitals developed in response to
    ◦ Urbanization
    ◦ Technology
    ◦ Medical specialization
   By 1900, 4,000 hospitals were in operation
   Originated to assure clean water, control
    epidemics
   Public health nursing gained strength
   Gradually took over
    immunizations, communicable
    disease, sanitation
   Public health remained separate from
    physician practice
   1916 to 1920
   Attempts by social reformers in 16 states to
    pass a bill requiring compulsory “health
    insurance” for workers
   Organized labor against it
   AMA “studied” it
   No surprise – no success
   Effects of Great Depression on hospitals and
    physicians
   Hospitals started a pre-payment plan
   Physician groups started a pre-payment plan
    for physician services in the hospital, mainly
    surgery
   Private companies saw their success and
    joined in – and a new industry was born
   1935 – Social Security Act
   1946 – Hill-Burton Act
   1952 – failed health care reform under
    President Truman
   1965 – Medicare and Medicaid passed in
    Lyndon Johnson’s vision for the Great Society
    ◦ Title VIII and Title XIX of the Social Security
      Amendment of 1965
   Attempts to bring more system-ness through
    National Health Planning Act of 1974
   Rise of HMOs
    ◦ HMO Act of 1973
   Rising costs



                                     National Health
                                  Planning Act of 1974

                                   HMO Act of 1973
   Rise of for-profit health care providers and
    organizations
   Increasing corporate dominance
   Vertical and horizontal integration of health
    care organizations
   Especially in 80s, private sector assumed
    substantial control of health care delivery
   Health Insurance and Portability and
    Affordability Act, 1996
   Balanced Budget Act,1997
   President Clinton’s health care reform
    attempt
   “A medical care system that had begun to
    attract investors and in which business
    interests had started to re-shape the
    behaviors of doctors and health care
    facilities…”
    ◦ Arnold Relman, MD
    ◦ Editor-in-Chief, New England Journal of
      Medicine, 1980
   http://money.cnn.com/magazines/fortune/fo
    rtune500/2010/performers/companies/profi
    ts/
   Driven by profits
   Driven by technology
This is America, isn’t it?
   Uninsured and underinsured do not have
    access to care (access)
   Costs continue to skyrocket (cost)
   Outcomes lag behind other developed
    countries (quality)
Uninsured
                 15%



Employer-               Medicaid/
Sponsored              Other Public
Insurance                 13%
  52%


                       Medicare
                         14%
            Private Non-
               Group
                 5%
Uninsured
          17%




 Medicaid/
Other Public
                    Employer-
   18%
                    sponsored
                    Insurance
                      60%
   Private Non-
       group
        5%
   66% uninsured families have 1or more full
    time worker(s)
   67% uninsured families below 200% poverty
    level
   Individuals between age 30 and 54 comprise
    the largest group of uninsured
   Patient Protection and Affordable Care Act
    (March 23, 2010)
    ◦ Far reaching changes to all aspects of health care
      system
    ◦ http://www.kff.org/healthreform/upload/8061.pdf
Why are we arguing about the
PPACA so hard?
   Health care as            Health care as
    economic model             social resource
   Assumes free              Requires
    market position            government
   Market-based               involvement
    demand for                Assumes
    services                   government led
   Services provided          position
    on ability to pay         Ability to pay not
   Access is reward for       necessary
    personal effort           Access is a right
   Individual              Collective
    responsibility for       responsibility for
    health                   health
   Benefits based on       Basic benefits for
    individual               everyone
    purchasing              Strong obligation to
   Limited obligation       collective good
    to collective good      Public solutions
   Private solutions       Planned rationing
   Rationing based on       of health care
    ability to pay

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SUSHCS

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