Assignment: (1) page paper, times new roman, 12 font. Please cite from textbook and website
Include the 4 questions in the paper
Real-World Case 1.1
1. How is the EHR (Electronic Health Record) changing the roles of the HIM (Health Information Management) staff?
2. What changes would you expect from the centralization of HIM (Health Information Management) functions?
3. What is your view of the HIM (Health Information Management) profession?
4. Visit the AHIMA website www.ahima.org and research the qualifications for taking each certification examination and the continuing education requirements for maintaining each credential. Compare and contrast the exams.
Turn in your typed one (1) page assignment in a word document, Times New Roman Times in a font size of 12.
Here’s the chapter reading from the textbook. See Below
Textbook: Health Information Management Technology An Applied Approach; 6th Edition, Author: Nanette B. Sayles, EdD, RHIA, CHPS, CCS, CPHIMS, FAHIMA
Healthcare Delivery Systems
Kelly Miller, MA, RHIA
Learning Objectives
Differentiate the roles of various healthcare providers throughout the healthcare delivery system
Determine the basic organization and operation of various types of hospitals and other healthcare organizations and services
Examine the use and functions of telehealth services in healthcare
Examine the influence of artificial intelligence in the delivery of healthcare
Identify the various policy making influences in the delivery of healthcare
Examine healthcare delivery in the United States
Key Terms
Accountable care organizations (ACOs)
Allied health professional
Ambulatory care
American Recovery and Reinvestment Act (ARRA)
Artificial intelligence (AI)
Average length of stay (ALOS)
Big data
Case management
Centers for Disease Control and Prevention (CDC)
Chief executive officer (CEO)
Chief financial officer (CFO)
Chief information officer (CIO)
Chief nursing officer (CNO)
Chief operating officer (COO)
Clinical privileges
Continuum of care
Critical access hospital (CAH)
Extended care facility
Health Information Technology for Economic and Clinical Health (HITECH) Act
Home healthcare
Hospice
Hospital
Hospitalist
Integrated delivery network (IDN)
Integrated delivery system (IDS)
Managed care organization (MCO)Medicaid
Medical home
Medical staff bylaws
Medical staff classification
Medicare
Patient Protection and Affordable Care Act (ACA)
Peer review organization (PRO)
Quality improvement organization (QIO)
Safety net hospital (SNH)
Skilled nursing facility (SNF)
Social determinants of health (SDOH)
Subacute care
Telehealth
Utilization review (UR)
Utilization Review Act
A broad array of healthcare services is available in the United States today, from simple preventive measures such as vaccinations to complex lifesaving procedures such as heart transplants. An individual’s contact with the healthcare delivery system often begins before he or she is born, with family planning and prenatal care, and continues through the end of life, when long-term care or hospice care may be needed.
Health information is a vital component of the healthcare system. Therefore, it is crucial for health information management professionals to have a comprehensive understanding of healthcare delivery. This chapter discusses healthcare delivery in the United States and how political, societal, and other factors have influenced its development. Well-known legislation affecting healthcare and healthcare information systems in the United States is examined. Different healthcare providers and types of delivery facilities and the services they provide are explained.
Healthcare Providers
The US healthcare system employs an estimated 16 million workers in the roles of health practitioners, practitioner support, technologists, technicians, and support roles (BLS 2017a). Physicians, nurses, and other clinical providers deliver healthcare services in a variety of healthcare settings. Those care settings include ambulatory, acute care, rehabilitative, psychiatric, long-term care, hospice, home care, assisted living centers, industrial medical clinics, and public health clinics. In other words, wherever people need access to the healthcare system, there are healthcare professionals providing that care.
Medical Practice
There are many providers included under the term medical practice, all of which are referred to as “doctor.” It should be noted that doctor is an educational degree, not a profession. Some of the most common healthcare practitioners are the following:
Chiropractor (DC—Doctor of Chiropractic) focuses on the diagnosis, treatment, and prevention of disorders of the neuromusculoskeletal system.
Dentist (DDS or DMD—Doctor of Dental Surgery or Doctor of Medicine in Dentistry) focuses on the diagnosis, prevention, and treatment of diseases and conditions of the oral cavity.
Medical (MD—Doctor of Medicine) focuses on the diagnosis, treatment, and education of any human disease or condition.
Optometrist (OD—Doctor of Optometry) focuses on vision and visual systems and is trained to prescribe and fit lenses to improve vision.
Osteopath (DO—Doctor of Osteopathic Medicine) not only focuses on manipulation of muscles and bones but also incorporates the diagnosis and treatment of diseases.
Podiatrist (DPM—Doctor of Podiatric Medicine) focuses on the treatment of disorders of the foot, ankle, and lower extremities.
All states require physicians be licensed to practice. Licensure requires graduating from a medical school with a Doctor of Medicine (MD) or a Doctor of Osteopathy (DO), successful completion of a licensing examination, and completion of a supervised residency program. Residencies are paid, on-the-job training that may last two to six years. Both MDs and DOs utilize acceptable treatment practices, including prescribing medications or performing surgeries.
The main difference between a DO and MD is in the philosophy and approach to medical treatment. The DO practices osteopathic medicine, which places an emphasis on the muscular system, stresses preventive medicine, and takes a holistic approach to patient care (Shi and Singh 2019). MDs practice allopathic medicine, which utilizes medical treatment as an active intervention to counteract and neutralize the effects of disease (Shi and Singh 2019). MDs may utilize preventive medicine combined with allopathic medicine. A 2016 census of active licensed physicians in the US identified 953,695 allopathic and osteopathic physicians serving a population of 323 million people. More than 90 percent of actively licensed physicians are MDs, compared to DOs (Young et al. 2016)
Physicians can be categorized as generalists or specialists. A generalist is trained in family medicine, general practice, general internal medicine, and general pediatrics. Generalists are considered primary care physicians. Non–primary care physicians are specialists. Specialists must obtain additional certification in their specialty. Medical specialties are divided into six major categories: 1) subspecialties of internal medicine 2) broad medical specialties 3) obstetrics and gynecology 4) surgery, 5) hospital-based radiology anesthesiology, and (6) psychiatry (Shi and Singh 2019). Some of the medical specialties and subspecialties are defined in figure 2.1. Some subspecialties can be included in more than one specialty category. For example, there is a subspecialty of pediatrics for most specialties.
Figure 2.1 Medical specialties and subspecialties
Medical Specialties and Subspecialties
Allergy and Immunology
Diagnoses and manages disorders involving immune conditions such as asthma, anaphylaxis, rhinitis, and eczema as well as adverse reactions to drugs, food, and insects. In addition, they diagnose and manage immune deficiency diseases and problems related autoimmune diseases, organ transplantation, or malignancies of the immune system.
Anesthesiology
Provides anesthesia for patients undergoing surgical, obstetric, diagnostic, or therapeutic procedures while monitoring the patient’s condition and supporting vital organ functions. Anesthesiologists also provide resuscitation and medical management for patients with critical illnesses and severe injuries.
Pediatric
Provides anesthesia for neonates, infants, children, and adolescents undergoing surgical, diagnostic, or therapeutic procedures as well as appropriate pre- and post-operative care, advanced life support, and acute pain management.
Colon and Rectal Surgery
Diagnoses and treats various diseases of the small intestine, colon, rectum, anal canal, and perianal area including the organs and tissues related to primary intestinal diseases.
Dermatology
Provides diagnosis and medical/surgical management of diseases of the skin, hair and nails, and mucous membranes.
Dermatopathology
Diagnoses and monitors diseases of the skin, including infectious, immunologic, degenerative, and neoplastic diseases
Emergency Medicine
Focuses on the immediate decision-making and action necessary to prevent death or any further disability both in the pre-hospital setting by directing emergency medical technicians and in the emergency department.
Family Medicine
Delivers a range of acute, chronic, and preventive medical care services to individuals of all ages, families, and communities. In addition to diagnosing and treating illness, these personal physicians manage chronic illness and provide preventive care, including routine checkups, health risk assessments, immunization and screening tests, and personalized counseling on maintaining a healthy lifestyle.
Geriatric Medicine
Includes special knowledge of the aging process and special skills in the diagnostic, therapeutic, preventive, and rehabilitative aspects of illness in the elderly.
Hospice and Palliative Medicine
Provides care to prevent and relieve the suffering experienced by patients with life-limiting illnesses.
Internal Medicine
Provides long-term, comprehensive care in the office and in the hospital, managing both common and complex illnesses of adolescents, adults, and the elderly. Internists are trained in the diagnosis and treatment of cancer, infections, and diseases affecting the heart, blood, kidneys, joints, and the digestive, respiratory, and vascular systems. They are also trained in the essentials of primary care internal medicine.
Cardiovascular Disease
Specializes in diseases of the heart and blood vessels and manages complex cardiac conditions, such as heart attacks and life-threatening, abnormal heartbeat rhythms.
Critical Care Medicine
Specializes in the diagnosis, treatment, and support of critically ill and injured patients, particularly trauma victims and patients with multiple organ dysfunction.
Neurocritical Care
Provides comprehensive multisystem care of the critically ill patient with neurological diseases and conditions.
Endocrinology, Diabetes, and Metabolism
Specializes in the diagnosis and management of disorders of hormones and their actions, metabolic disorders, and neoplasia of the endocrine glands.
Gastroenterology
Specializes in diagnosis and treatment of diseases of the digestive organs including the stomach, bowels, liver, and gallbladder.
Hematology
Specializes in diseases of the blood, spleen, and lymph.
Infectious Disease
Provides care for infectious diseases of all types and in all organ systems. Infectious disease specialists may also have expertise in preventive medicine and travel medicine.
Interventional Cardiology
Uses specialized imaging and other diagnostic techniques to evaluate blood flow and pressure in the coronary arteries and chambers of the heart, and uses technical procedures and medications to treat abnormalities that impair the function of the cardiovascular system.
Medical Oncology
Diagnoses and treats all types of cancer and other benign and malignant tumors.
Nephrology
Treats disorders of the kidney, high blood pressure, fluid and mineral balance, and dialysis of body wastes when the kidneys do not function.
Pulmonary Disease
Treats diseases of the lungs and airways. Diagnoses and treats cancer, pneumonia, pleurisy, asthma, occupational and environmental diseases, bronchitis, sleep disorders, emphysema, and other complex disorders of the lungs.
Rheumatology
Treats diseases of joints, muscle, bones, and tendons. Diagnoses and treats arthritis, back pain, muscle strains, common athletic injuries, and collagen diseases.
Medical Genetics and Genomics
Specializes in medicine that involves the interaction between genes and health. Medical geneticists are trained to evaluate, diagnose, manage, treat, and counsel individuals of all ages with hereditary disorders. These specialists use modern cytogenetic, molecular, genomic, and biochemical genetic testing to assist in specialized diagnostic evaluations, implement needed therapeutic interventions, and provide genetic counseling and prevention through prenatal and preimplantation diagnosis.
Neurological Surgery
Treats adult and pediatric patients for pain or pathological processes that may modify the function or activity of the central nervous system, the peripheral nervous system, the autonomic nervous system, the supporting structures of these systems, and their vascular supply.
Neurology
Evaluates and treats all types of diseases or impaired functions of the brain, spinal cord, peripheral nerves, muscles, and autonomic nervous system, as well as the blood vessels that relate to these structures.
Brain Injury Medicine
Focuses on the prevention, evaluation, treatment, and rehabilitation of individuals with acquired brain injury.
Clinical Neurophysiology
Evaluates and treats central, peripheral, and autonomic nervous system disorders using a combination of clinical evaluation and electrophysiologic testing such as electroencephalography (EEG), electromyography (EMG), and nerve conduction studies (NCS). Practitioners may be neurologists, pediatric neurologists, or psychiatrists.
Epilepsy
Evaluates and treats adults and children with recurrent seizure activity and seizure disorders. Neurologists and pediatric neurologists provide epilepsy care.
Obstetrics and Gynecology
Focuses on the health of women before, during, and after childbearing years, diagnosing and treating conditions of the reproductive system and associated disorders.
Complex Family Planning
Diagnoses and treats women with medically and surgically complex conditions.
Maternal–Fetal Medicine
Focuses on patients with complications of pregnancy and the effects on both the mother and the fetus.
Reproductive Endocrinology and Infertility
Concentrates on hormonal functioning as it pertains to reproduction as well as the issue of infertility. These specialists also are trained to evaluate and treat hormonal dysfunctions in females outside of infertility.
Ophthalmology
Prescribes eyeglasses and contact lenses, dispenses medications, diagnoses and treats eye conditions and diseases, and performs surgeries. Ophthalmologists are the only physicians medically trained to manage the complete range of eye and vision care.
Orthopaedic Surgery
Focuses on the preservation, investigation, and restoration of the form and function of the extremities, spine, and associated structures by medical, surgical, and physical means.
Otolaryngology – Head and Neck Surgery
Provides medical and surgical therapy for the prevention of diseases, allergies, neoplasms, deformities, disorders, and injuries of the ears, nose, sinuses, throat, respiratory, and upper alimentary systems, face, jaws, and the other head and neck systems.
Pain Medicine
Provides care for patients with acute, chronic, or cancer pain in both inpatient and outpatient settings while coordinating patient care needs with other specialists.
Pathology
Deals with the causes and nature of disease and contributes to diagnosis, prognosis, and treatment through knowledge gained by the laboratory application of the biological, chemical, and physical sciences.
Pediatrics
Focuses on the physical, emotional, and social health of children from birth to young adulthood. Pediatric care encompasses a broad spectrum of health services ranging from preventive healthcare to the diagnosis and treatment of acute and chronic diseases.
Adolescent Medicine
Focuses on the unique physical, psychological, and social characteristics of adolescents, and their healthcare problems and needs.
Physical Medicine and Rehabilitation
Evaluates and treats patients with physical or cognitive impairments and disabilities that result from musculoskeletal conditions (such as neck or back pain, or sports or work injuries), neurological conditions (such as stroke, brain injury, or spinal cord injury), or other medical conditions. Also called a physiatrist.
Plastic Surgery
Deals with the repair, reconstruction, or replacement of physical defects of form or function involving the skin, musculoskeletal system, craniomaxillofacial structures, hand, extremities, breast and trunk, and external genitalia or cosmetic enhancement of these areas of the body. Cosmetic surgery is an essential component of plastic surgery
Preventive Medicine
Focuses on the health of individuals and defined populations to protect, promote, and maintain health and well-being and to prevent disease, disability, and premature death.
Addiction Medicine
Concerned with the prevention, evaluation, diagnosis, and treatment of persons with the disease of addiction, of those with substance-related health conditions, and of people who show unhealthy use of substances including nicotine, alcohol, prescription medications, and other licit and illicit drugs.
Clinical Informatics
Collaborates with other healthcare and information technology professionals to analyze, design, implement, and evaluate information and communication systems that enhance individual and population health outcomes, improve patient care, and strengthen the clinician–patient relationship.
Medical Toxicology
Specializes in the prevention, evaluation, treatment, and monitoring of injury and illness from exposures to drugs and chemicals, as well as biological and radiological agents.
Psychiatry
Evaluates and treats mental, addictive, and emotional disorders such as schizophrenia and other psychotic disorders, mood disorders, anxiety disorders, substance-related disorders, sexual and gender-identity disorders, and adjustment disorders.
Radiology
Utilizes imaging methodologies to diagnose and manage patients and provide therapeutic options.
Diagnostic
Utilizes x-rays, radionuclides, ultrasound, and electromagnetic radiation to diagnose and treat disease.
Interventional Radiology and Diagnostic Radiology
Combines competence in imaging, image-guided minimally invasive procedures, and peri-procedural patient care to diagnose and treat benign and malignant conditions of the thorax, abdomen, pelvis, and extremities.
Radiation Oncology
Uses ionizing radiation and other modalities to treat malignant and some benign diseases.
Neuroradiology
Diagnoses and treats disorders of the brain, sinuses, spine, spinal cord, neck, and the central nervous system, such as aging and degenerative diseases, seizure disorders, cancer, stroke, cerebrovascular diseases, and trauma.
Nuclear Radiology
Uses the administration of trace amounts of radioactive substances (radionuclides) to provide images and information for making a diagnosis.
Sleep Medicine
Diagnoses and manages clinical conditions that occur during sleep, that disturb sleep, or that are affected by disturbances in the wake-sleep cycle. Includes the analysis and interpretation of comprehensive polysomnography, and practitioners are well versed in emerging research and management of a sleep laboratory.
Sports Medicine
Focuses on the prevention, diagnosis, and treatment of injuries related to participating in sports or exercise.
Surgery (General)
Provides diagnosis and care of patients with diseases and disorders affecting the abdomen, digestive tract, endocrine system, breast, skin, and blood vessels. General surgeons are skilled in the use of minimally invasive techniques and endoscopies. Common conditions treated by general surgeons include hernias, gallstones, appendicitis, breast tumors, thyroid disorders, pancreatitis, bowel obstructions, colon inflammation, and colon cancer.
Thoracic Surgery
Encompasses the operative, perioperative, and surgical critical care of patients with acquired and congenital pathological conditions within the chest.
Congenital Cardiac Surgery
Refers to the procedures that are performed to repair the many types of heart defects that may be present at birth and can occasionally go undiagnosed into adulthood.
Urology
Focuses on diagnosing and treating disorders of the urinary tracts of males and females, and on the reproductive system of males. Manages nonsurgical problems such as urinary tract infections, as well as surgical problems such as the correction of congenital abnormalities.
Female Pelvic Medicine and Reconstructive Surgery
Provides consultation and comprehensive management of women with complex benign pelvic conditions, lower urinary tract disorders, and pelvic floor dysfunction.
Source: Adapted from American Board of Medical Specialties (ABMS).2019. ABMS Guide to Medical Specialties. https://www.abms.org/media/194925/abms-guide-to-medical-specialties-2019.pdf
Another specific role for physicians is that of a hospitalist. A hospitalist is a physician who specializes in the care of inpatient hospital patients (Shi and Singh 2019). Typically, hospitalists do not have a relationship with the patient prior to providing care during the hospitalization. In the traditional inpatient model, the patient’s primary care physician would oversee their care. In the hospitalist model, the hospitalist oversees the patient’s care until discharge; then the patient returns to the care of their primary care physician.
Hospitalists were first utilized to provide care for unassigned patients on general medicine floors and to cover for community-based primary care physicians. As hospitals began to focus on managed care, hospitalists were viewed as a means for hospitals to gain greater efficiency (Furci and Furci 2017). With the use of hospitalists, primary care physicians can devote more time to their office practices. There are approximately 50,000 hospitalists practicing in 75 percent of US Hospitals (Wachter and Goldman 2016).
Physician Assistants
Some physicians and healthcare facilities employ physician assistants (PAs) to help carry out clinical responsibilities. PAs practice medicine with teams of physicians, surgeons, and other healthcare workers to examine, diagnose, and treat patients. They work in a variety of clinical settings. A PA is licensed to provide care and perform medical procedures only under the supervision of a physician. In most states PAs have the authority to prescribe medications. Employment of PAs is projected to grow 37 percent from 2016 to 2026 (BLS 2018).
Nursing Practice
Nurses represent the largest number of healthcare professionals with four million registered nurses (RNs) (ANA 2019). Nurses are the primary caregivers for sick and injured patients. They use their judgment to integrate objective data with subjective observation of the patient’s biological, physical, and behavioral needs. Nurses work in a variety of health settings, from providing critical care to vaccinations in a physician practice. The American Nurses Association (2019) provides the following four key responsibilities of registered nurses (ABMS 2019):
1. Perform physical exams and health histories before making critical decisions
2. Provide health promotion, counseling, and education
3. Administer medications and other personalized interventions
4. Coordinate care in collaboration with a wide array of healthcare professionals
Most RNs have either a two-year associate degree or a four-year bachelor of science degree from a state-approved nursing school, though some schools offer a master’s degree that allows the graduate to sit for the licensure examination. Nurse practitioners, researchers, educators, and administrators generally have a four-year degree in nursing and additional postgraduate education in nursing. The postgraduate degree may be a master of science or a doctorate in nursing. Nurses who graduate from nonacademic training programs are called licensed practical nurses (LPNs) or licensed vocational nurses (LVNs). Non-degreed nursing personnel work under the direct supervision of RNs. Nurses must be licensed in the state in which they are working. They may be licensed in more than one state through examination or endorsement of a license issued by another state.
Today’s RNs are highly trained clinical professionals. Many nurses specialize in specific areas of practice such as surgery, psychiatry, or intensive care. Nurse-midwives complete advanced training and are certified by the American College of Nurse-Midwives. Similarly, nurse-anesthetists are certified by the Council on Certification/Council on Recertification of Nurse Anesthetists. Nurse practitioners also receive advanced training at the master’s level that qualifies them to provide primary care services to patients. They are certified by several organizations (for example, the National Board of Pediatric Nurse Practitioners) to practice in the area of their specialty.
The need for RNs is expected to rise over the next decade. Hospitals in the US report continued vacancies for RNs. The Bureau of Labor Statistics estimates that between the years 2016 and 2026 approximately 438,100 more RNs will be needed over the projected supply (BLS 2017b).
Allied Health Professions
After World War I, many roles previously assumed by nurses and nonclinical personnel began to change. With the advent of modern diagnostic and therapeutic technology in the mid-20th century, the complex skills needed by ancillary medical personnel fostered the growth of specialized training programs and professional accreditation and licensure.
According to the Association of Schools of Allied Health Professions (ASAHP), allied health encompasses a broad group of health professionals who use scientific principles and evidence-based practice for the diagnosis, evaluation, and treatment of acute and chronic diseases; promote disease prevention and wellness for optimum health; and apply administration and management skills to support healthcare systems in a variety of settings. The Health Professions Education Extension Amendment of 1992, which amended the Public Health Service Act, describes allied health professionals as health professionals (other than registered nurses, physicians, and physician assistants) who have received a certificate, an associate degree, a bachelor degree, a master degree, a doctorate, or postdoctoral training in a healthcare-related science. Such individuals share responsibility for the delivery of healthcare services with clinicians (physicians, nurses, and physician assistants).
Allied health plays an essential role in the delivery of healthcare. It is estimated that as much as 60 percent of the US healthcare workforce can be classified as allied health (ASAHP 2018). Professions that fall in the category of allied health are the non-nurse, non-physician healthcare providers. The formal education requirements for these professions range from certifications through postsecondary education to postgraduate degrees. Technicians and assistants such as a physical therapist assistant, dental assistant, or laboratory technician typically receive less than two years postsecondary education and must work under the supervision of a therapist or technologist. Therapists such as a physical or speech therapist receive more advanced training.
The following list briefly describes some of the major occupations usually considered to be allied health professions:
Audiology. Audiology is the branch of science that studies hearing, balance, and related disorders. Audiologists treat those with hearing loss and proactively prevent related damage. According to the American Speech-Language-Hearing Association, audiologists provide comprehensive diagnostic and treatment or rehabilitative services for auditory and related impairments. These services are provided to all individuals regardless of age, socioeconomic status, ethnicity, or cultural backgrounds (ASHA 2016).
Clinical laboratory science. Originally referred to as medical laboratory technology, this field is now known as clinical laboratory science. Clinical laboratory technicians perform a wide array of tests on body fluids, tissues, and cells to assist in the detection, diagnosis, and treatment of diseases and illnesses. The clinical laboratory is divided into two sections—anatomic pathology and clinical pathology. Anatomic pathology deals with human tissues and provides surgical pathology, autopsy, and cytology services. Clinical pathology deals mainly with the analysis of body fluids—principally blood, but also urine, gastric contents, and cerebrospinal fluid. Physicians who specialize in performing and interpreting the results of pathology tests are called pathologists. Laboratory technicians are allied health professionals trained to operate laboratory equipment and perform laboratory tests under the supervision of a pathologist.
Diagnostic medical sonography or imaging technology. Originally referred to as x-ray technology and then radiologic technology, this field is now referred to as diagnostic imaging. The field continues to expand to include nuclear medicine, radiation therapy, and echocardiography. Physician specialists (radiologists) and technologists including radiation therapists, cardiosonographers (ultrasound technologists), and magnetic resonance imaging technologists provide these services. Nuclear medicine involves the use of ionizing radiation and small amounts of short-lived radioactive tracers to treat disease, specifically neoplastic disease (that is, nonmalignant tumors and malignant cancers). Radiation therapy uses high-energy x-rays, cobalt, electrons, and other sources of radiation to treat human disease. In current practice, radiation therapy is used alone or in combination with surgery or chemotherapy (drugs) to treat many types of cancer. In addition to external beam therapy, radioactive implants (as well as therapy performed with heat—hyperthermia) are available.
Dietetics and nutrition. Dietitians (also clinical nutritionists) are trained in nutrition. They are responsible for providing nutritional care to individuals and for overseeing nutrition and food services in a variety of settings, ranging from hospitals to schools.
Emergency medical technology. Emergency medical technicians (EMTs) and paramedics provide a wide range of services on an emergency basis for cases of traumatic injury and other emergency situations and in the transport of emergency patients to a healthcare organization.
Health information management. Health information management (HIM) professionals. Registered Health Information Administrators (RHIAs) and Registered Health Information Technicians (RHITs) are the credentials for HIM professions. They are responsible for ensuring the availability, accuracy, and protection of the clinical information that is needed to deliver healthcare services and to make appropriate healthcare-related decisions.
Occupational therapy. Occupational therapists (OTs) use work and play activities to improve patients’ independent functioning, enhance their development, and prevent or decrease their level of disability. Occupational therapy activities may involve the adaptation of tasks or the environment to achieve maximum independence and to enhance the patient’s quality of life and improve his or her activities of daily living (ADL). An occupational therapist may treat developmental deficits, birth defects, learning disabilities, traumatic injuries, burns, neurological conditions, orthopedic conditions, mental deficiencies, and psychiatric disorders. Working under the direction of physicians, occupational therapy is made available in acute-care hospitals, clinics, and rehabilitation centers.
Optometry. Optometry is a health profession that is focused on the eyes and related structures, as well as vision, visual systems, and vision information processing in humans. Optometrists provide treatments such as contact lenses and corrective and low-vision devices and are authorized to use diagnostic and therapeutic pharmaceutical agents to treat anterior segment disease, glaucoma, and ocular hypertension. As primary eye care practitioners, optometrists often are the first ones to detect such potentially serious conditions as diabetes, hypertension, and arteriosclerosis.
Pharmacy. Traditionally the role of a pharmacist was to dispense medications and to provide consultation on the proper selection and use of medications. Prior to 2005, the bachelor’s degree was the standard for pharmacists. The current standard is a PharmD, which requires six years of postsecondary education. The scope of practice for a pharmacist is expanding into specialty areas such as pharmacotherapy. Pharmacotherapists work closely with physicians and specialize in drug therapy. Pharmacists take an active role in pharmaceutical care of patients by assisting prescribers in appropriate drug choices, by effecting distribution of medications to patients, and by assuming direct responsibility to collaborate with other healthcare providers and the patient to achieve a desired therapeutic outcome (Shi and Sing 2019).
Physical therapy. Physical therapists (PTs), who work under the direction of a physician, evaluate and treat patients to improve functional mobility, reduce pain, maintain cardiopulmonary function, and limit disability. PTs treat movement dysfunction resulting from accidents, trauma, stroke, fractures, multiple sclerosis, cerebral palsy, arthritis, and heart and respiratory illness. Treatment modalities include therapeutic exercise, therapeutic massage, biofeedback, and applications of heat, low-energy lasers, cold, water, electricity, and ultrasound.
Respiratory therapy. Respiratory therapists (RTs) evaluate, treat, and care for patients with acute or chronic lung disorders. They work under the direction of qualified physicians and provide services such as emergency care for stroke, heart failure, and shock. In addition, they treat patients with emphysema and asthma. Respiratory treatments include the administration of oxygen and inhalants such as bronchodilators and setting up and monitoring ventilator equipment.
Speech-language pathology. Speech-language pathologists and audiologists identify, assess, and provide treatment for individuals with speech, language, or hearing problems.
Surgical technologist. Surgical technologists provide surgical care to patients in a variety of settings; the majority are hospital operating rooms. Surgical technologists work under medical supervision to facilitate the safe and effective conduct of invasive surgical procedures (Kickman and Kovner 2015).
The occupations in the healthcare industry with the largest number of employees include RNs and personal care aides. Figure 2.2 shows the number of employees by field in healthcare and the social assistance industry.
Figure 2.2 Largest occupations in healthcare and the social assistance industry
Source: BLS 2017c.
Organization and Operation of Modern Hospitals
During the 1990s, hospitals in the United States faced growing pressure to contain costs, improve quality, and demonstrate how they contributed to the health of the communities they served. Hospitals responded to these pressures in various ways. Some hospitals merged with other hospitals and healthcare facilities, or they were bought out. Other hospitals created integrated delivery systems (IDSs). These are healthcare systems that combine the financial and clinical aspects of healthcare and use a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care. The IDSs were created to provide a full range of healthcare services along the continuum of care, from ambulatory care to inpatient care to long-term care. The continuum of care places an emphasis on treating individual patients at the level of care required by their course of treatment and extends from their primary care providers to specialists and ancillary providers. In 2014, the American Hospital Association released “Your Hospital’s Path to the Second Curve: Integration and Transformation.” This paper discusses the shift in the healthcare field from the “first curve,” where hospitals operate in a volume-based environment to the “second curve” where they build value-based care systems (AHA 2014). Hospitals and care systems need to redesign how care is delivered to eliminate inefficiencies within the system that will lead to better, integrated care, and lower total cost of care. The establishment of IDSs, the greater use of teams, and leveraging the skills and capabilities of all providers in different settings within the IDS is a step towards achieving patient-centered care and the second curve environment.
Others have concentrated on improving the care they provide by focusing on patients as customers. Many hospitals responded to local competition by quickly entering into affiliations and other risk-sharing agreements with acute- and nonacute-care providers, physicians’ groups, and managed care organizations (MCOs)—a type of healthcare organization that delivers medical care and manages all aspects of patient care or the payment for care by limiting providers of care, discounting payments to providers of care, or limiting access to care.
While most hospitals are integrated into their communities through ties with area physicians and other healthcare providers, clinics and outpatient facilities, and other practitioners, almost half the nation’s hospitals also are tied to larger organizational entities such as multihospital and integrated healthcare systems (IHCSs), integrated delivery networks (IDNs), and alliances. An IDN comprises a group of hospitals, physicians, other providers, insurers, or community agencies that work together to deliver health services. In 2015, 55 percent of all hospitals in the US belonged to an IDN (AHA 2015).
By the end of 2010, healthcare organizations faced the challenges of a stressed economy. Hospital reimbursement payments continued to shrink as a result of higher unemployment and more uninsured individuals throughout the nation. At that time, hospitals reached out for opportunities to control costs, streamline operations, implement efficient information technologies, engage in quality initiatives, and pursue joint ventures and consolidation. Today, hospitals are a dominant player in the healthcare system and have a significant impact on the US economy. According to the American Hospital Association (AHA), in 2016 hospitals treated 143 million people in their emergency departments, provided 605 million outpatient visits, performed over 27 million surgeries, and delivered nearly 4 million infants. In addition to providing vital healthcare services, hospitals employ nearly 6 million people and are one of the top sources of private-sector jobs (AHA 2018b). In 2017, healthcare expenditures in the United States were approximately $3.5 trillion, which represented 17.9 percent of the total American economy (CMS 2018a). According to Centers for Medicare and Medicaid Services (CMS) projections, national health spending is projected to grow an average rate of 5.5 percent each year and reach $5.7 trillion by 2026 (CMS 2018b). Figure 2.3 shows the national health expenditures in 2017 were $3.5 trillion dollars, with 45 percent going toward hospital care.
Figure 2.3 National health expenditures in 2017
Source: Adapted from CMS 2018a.
The term hospital can be applied to any healthcare facility that does the following:
Has an organized medical staff
Provides permanent inpatient beds
Offers around-the-clock nursing services
Provides diagnostic and therapeutic services
Most hospitals provide acute-care services to inpatients. Acute care is the short-term care provided to diagnose or treat an illness or injury. The individuals who receive acute-care services in hospitals are considered inpatients. Inpatients receive room-and-board services in addition to continuous nursing services. Generally, patients who spend more than 24 hours in a hospital are considered inpatients.
Hospitals that have an average length of stay (ALOS) of 25 days or less are considered acute-care hospitals. Hospitals that have ALOSs longer than 25 days are considered long-term acute-care facilities. Long-term care is discussed in detail later in this chapter. The ALOS is the mean length of stay for hospital inpatients discharged during a given period of time. With recent advances in surgical technology, anesthesia, and pharmacology, the ALOS in an acute-care hospital is much shorter today than it was only a few years ago. In addition, many diagnostic and therapeutic procedures that once required inpatient care now can be performed on an outpatient basis.
For example, before the development of laparoscopic surgical techniques, a patient might be hospitalized for 10 days after a routine appendectomy (surgical removal of the appendix). Today, a patient undergoing a laparoscopic appendectomy might spend only a few hours in the hospital’s outpatient surgery department and go home the same day. The influence of managed care and the emphasis on cost control in the Medicare or Medicaid programs also have resulted in shorter hospital stays. More information on healthcare statistics can be found in chapter 14, Healthcare Statistics.
In large acute-care hospitals, hundreds of clinicians, administrators, managers, and support staff must work closely to provide effective and efficient diagnostic and therapeutic services. Most hospitals provide services to both inpatients and outpatients. A hospital outpatient is a patient who receives hospital services without being admitted for inpatient (overnight) hospital care. Outpatient care is considered ambulatory care. (Ambulatory care is discussed later in this chapter.)
Types of Hospitals
There are many types of hospitals providing care within the US healthcare system. The five major criteria used to classify hospital types are the following:
1. Functionality
2. Location
3. Number of beds
4. Specialization
5. Types of ownership
Functionality
This refers to how the hospitals function within the communities they serve. They could be general, teaching, acute care, long term, community, and research or trauma centers.
Location
Hospitals can be classified by their location. Rural hospitals may have limited access to advanced equipment or specialized procedures. Urban hospitals serve larger metropolitan areas and often offer a wide degree of versatility when it comes to treatment options.
Number of Beds
A hospital’s number of beds refers to the beds that are equipped and staffed for patient care. The term bed capacity sometimes is used to reflect the maximum number of inpatients for which the hospital can care. Licensed beds are the number of beds that the state has authorized the hospital to have available for patients and staffed beds refers to the number of beds for which the hospital has nursing staff to cover patient treatment. A hospital is usually considered small if it has fewer than 100 beds. Most US hospitals fall into this category. Some large, urban hospitals may have more than 500 beds. The number of beds is usually broken down by adult and pediatric beds. The number of maternity beds and other special categories may be listed separately. Hospitals also can be categorized according to the number of outpatient visits per year.
Specialization
A hospital may specialize in certain types of services and treatment of specific illnesses. The following are examples:
Rehabilitation hospitals generally provide long-term care services to patients recuperating from debilitating or chronic illnesses and injuries such as strokes, head and spine injuries, and gunshot wounds. Patients often stay in rehabilitation hospitals for several months.
Psychiatric hospitals provide inpatient care for patients with mental and developmental disorders. In the past, the ALOS for psychiatric inpatients was longer than it is today. Rather than months or years, most patients now spend only a few days or weeks per stay. However, many patients require repeated hospitalization for chronic psychiatric illnesses.
General hospitals provide a wide range of medical and surgical services to diagnose and treat most illnesses and injuries.
Specialty hospitals provide diagnostic and therapeutic services for a limited range of conditions such as burns, cancer, tuberculosis, obstetrics, or gynecology.
Long-term acute-care hospitals (LTACHs) specialize in the treatment of patients with serious medical conditions that require care on an ongoing basis. These patients do not require intensive care or extensive diagnostic procedures but require more care than they can receive in a rehabilitation center, skilled nursing facility, or home.
Types of Ownership
The most common ownership types for hospitals and other kinds of healthcare organizations in the United States include the following:
Government-owned hospitals which are operated by a specific branch of federal, state, or local government as not-for-profit organizations. (Government-owned hospitals sometimes are called public hospitals.) They are supported, at least in part, by tax dollars. Examples of federally owned and operated hospitals include those operated by the Department of Veterans Affairs (VA) to serve retired military personnel. The Department of Defense operates facilities for active military personnel and their dependents. Many states own and operate psychiatric hospitals. County and city governments often operate public (municipal) hospitals to serve the healthcare needs of their communities, especially those residents who are unable to pay for their care.
Proprietary hospitals may be owned by private foundations, partnerships, or investor-owned corporations. Large corporations may own a number of for-profit hospitals, and the stocks of several large US hospital chains are traded publicly.
Voluntary hospitals are not-for-profit hospitals owned by universities, churches, charities, religious orders, unions, and other not-for-profit entities. They often provide free care to patients who otherwise would not have access to healthcare services.
Hospitals also can be classified based on their ownership and profitability status. Not-for-profit healthcare facilities use excess funds to improve their services and to finance educational programs and community services. For-profit healthcare organizations are privately owned. Excess funds are paid back to the managers, owners, and investors in the form of bonuses and dividends.
Safety Net Hospitals
A safety net hospital (SNH) is defined as a hospital with the highest number of inpatient stays paid by Medicaid. Uninsured safety net organizations play a major role in providing services to medically and socially vulnerable populations. When compared with non-SNHs, SNHs are more likely to be teaching hospitals, have a large number of inpatient beds, and just over 27 percent are located in large central metropolitan areas (Sutton et al. 2016).
Critical Access Hospitals
As part of the Balanced Budget Act of 1997 (discussed later in this chapter), CMS was authorized to allow certain healthcare organizations the designation of critical access hospital (CAH). By meeting certain requirements these hospitals are allowed a separate payment system that allows reimbursement for Medicare patients at 101 percent of reasonable costs and are not subject to the inpatient prospective payment system (IPPS) or the hospital outpatient prospective payment system (OPPS). The criteria to qualify as a CAH are as follows (see chapter 15, Revenue Management and Reimbursement for more details on IPPS and OPPS):
Be located in a state that accepted a grant under the Medicare Rural Hospital Flexibility Program, which helps states to strengthen their rural healthcare infrastructure
Be located in a rural area
Furnish 24-hour emergency care services 7 days a week
Maintain no more than 25 inpatient beds that may also be used as swing beds (hospital beds that can be either acute-care or skilled nursing facility beds)
Have an annual length of stay of 96 hours or less per patient for acute-care services
Be located more than a 35-mile distance from any other hospital
Be certified as a CAH prior to January 1, 2006 (CMS 2014)
Organization of Hospital Services
The organizational structure of every hospital is designed to meet its specific needs. For example, most acute-care hospitals are comprised of a professional medical staff and hospital administrative services, which include an executive administrative staff, medical and surgical services, patient care (nursing) services, diagnostic and laboratory services, and support services (for example, nutritional services, environmental safety, and HIM services). Hospitals are overseen by a board of directors.
Board of Directors
The board of directors (also known as the governing board or board of trustees) has primary responsibility for setting the overall direction of the hospital. The board works with the chief executive officer (CEO) and the leaders of the organization’s medical staff to develop the hospital’s strategic direction as well as its mission (statement of the hospital’s purpose and the customers it serves), vision (description of the hospital’s ideal future), and values (descriptive list of the organization’s fundamental principles or beliefs). Chapter 17, Management, covers mission, vision, and values in more detail.
The board of directors’ other responsibilities include the following:
Establishing bylaws in accordance with the organization’s legal and licensing requirements
Selecting qualified administrators
Approving the organization and makeup of the clinical staff
Monitoring the quality of care
Board members are elected or appointed to serve a specific term (for example, five years). Boards may elect officers, commonly a chairman, vice-chairman, president, secretary, and treasurer. The size of the board varies. Individual board members are called directors, board members, or trustees. Individuals serve on one or more standing committees such as the executive committee, joint conference committee, finance committee, strategic planning committee, and building committee.
The makeup of the board depends on the type of hospital and the form of ownership. For example, the board of a community hospital is likely to include local business leaders, representatives of community organizations, and other people interested in the welfare of the community. The board of a teaching hospital, on the other hand, is likely to include medical school alumni and university administrators, among others.
Increased competition among healthcare providers and limits on managed care and Medicare or Medicaid reimbursement have made the governing of hospitals especially difficult in the past two decades. In the future, boards of directors will continue to face strict accountability in terms of cost containment, performance management, and integration of services to maintain fiscal stability and to ensure the delivery of high-quality patient care.
Medical Staff
The medical staff consists of physicians who have received extensive training in various medical disciplines (internal medicine, pediatrics, cardiology, gynecology and obstetrics, orthopedics, surgery, and so on). The medical staff’s primary objective is to provide high-quality patient care to the patients who come to the hospital. The physicians on the hospital’s medical staff diagnose illnesses and develop patient-centered treatment regimens. Moreover, they may serve on the hospital’s governing board, where they provide critical insight relevant to strategic and operational planning and policy making.
The medical staff is the aggregate of physicians who have been granted permission to provide clinical services in the hospital. This permission is called clinical privileges. An individual physician’s privileges are limited to a specific scope of practice. For example, an internal medicine physician would be permitted to diagnose and treat a patient with pneumonia, but not to perform a surgical procedure. Traditionally, most members of the medical staff have not been employees of the hospital, although this is changing as many hospitals are purchasing physician practices.
Medical staff classification refers to the organization of physicians according to clinical assignment. Depending on the size of the hospital and on the credentials and clinical privileges of its physicians, the medical staff may be separated into departments such as medicine, surgery, obstetrics, pediatrics, and other specialty services. Typical medical staff classifications include active, provisional, honorary, consulting, courtesy, and medical resident assignments.
Officers of the medical staff usually include a president or chief of staff, a vice president or chief of staff elect, and a secretary. These officers are authorized by a vote of the entire active medical staff. The president presides over all regular meetings of the medical staff and is an ex officio member of all medical staff committees. The secretary keeps the minutes from the meetings and ensures they are accurate and complete. The secretary also handles correspondence appropriately.
The medical staff operates according to a predetermined set of policies called the medical staff bylaws. The bylaws state the specific qualifications a physician must demonstrate before he or she can practice medicine in the hospital. The bylaws are considered legally binding. The medical staff and the hospital’s governing body must vote to approve any changes to the bylaws.
Administrative Staff
The CEO or chief administrator is the leader of the administrative staff. The CEO implements the policies and strategic direction set by the hospital’s board of directors. The CEO is also responsible for building an effective executive management team and coordinating the hospital’s services. Today, healthcare organizations commonly designate the following roles as the executive management team: chief financial officer (CFO), the senior manager responsible for the fiscal management of an organization; a chief operating officer (COO), the executive responsible for high-level, day-to-day operations; and a chief information officer (CIO), the senior manager responsible for the management of the information resources.
The executive management team is responsible for managing the hospital’s finances and ensuring the hospital complies with the federal, state, and local rules, standards, and laws that govern the delivery of healthcare services. Depending on the size of the hospital, the CEO’s staff may include healthcare administrators with job titles such as vice president, associate administrator, department director or manager, or administrative assistant. Department-level administrators manage and coordinate the activities of the highly specialized and multidisciplinary units that perform clinical, administrative, and support services in the hospital.
Healthcare administrators may hold advanced degrees in healthcare administration, nursing, public health, or business management. A growing number of hospitals are hiring physician executives to lead their executive management teams.
Patient Care Services
Most direct patient care delivered in hospitals is provided by professional nurses. Modern nursing requires a diverse skill set, advanced clinical competencies, and postgraduate education. In almost every hospital, patient care services constitute the largest clinical department in terms of staffing, budget, specialized services offered, and clinical expertise required.
Nurses are responsible for providing continuous, around-the-clock treatment and support for hospital inpatients. The quantity and quality of nursing care available to patients is influenced by a number of factors, including the nursing staff’s educational preparation and specialization, experience, and skill level. The level of patient care staffing also is a critical component of quality.
Traditionally, physicians alone determined the type of treatment each patient would receive. However, today’s nurses are playing a wider role in treatment planning and case management. They perform an ongoing, concurrent review to ensure the necessity and effectiveness of the clinical services being provided to patients. Their responsibilities include performing patient assessments, creating care plans, evaluating the appropriateness of treatment, and evaluating the effectiveness of care. At the same time, they provide technical care and offer personal care that recognizes the concerns and emotional needs of patients and their families.
An RN who is qualified by advanced education and clinical and management experience usually administers patient care services. Although the title may vary, this role is usually referred to as the chief nursing officer (CNO) or vice president of nursing or patient care. The CNO is a member of the hospital’s executive management team and usually reports directly to the CEO.
Diagnostic Services
The services provided to patients in hospitals go beyond the clinical services provided directly by the medical and nursing staff. Many diagnostic and therapeutic services involve the work of allied health professionals. Allied health professionals receive specialized education and training, and their qualifications are registered or certified by a number of specialty organizations.
Diagnostic and therapeutic services are critical to the success of every patient care delivery system. Diagnostic services include clinical laboratory, radiology, and nuclear medicine. Therapeutic services include clinical laboratory services, radiology, and radiation therapy.
Rehabilitation Services
Rehabilitation services are dedicated to eliminating the patient’s disability or alleviating it as fully as possible. The goal is to improve the cognitive, social, and physical abilities of patients impaired by chronic disease or injury. Rehabilitation services can be provided within the acute-care setting or in specialty hospitals dedicated to providing many forms of rehabilitation to patients to facilitate their return to work or home. The rehabilitation team may include physicians, nurses, occupational therapists, physical therapists, respiratory therapists, speech therapists, social workers, and other healthcare personnel.
Ancillary Support Services
The ancillary units of the hospital provide vital clinical and administrative support services to patients, medical staff, visitors, and employees.
The clinical support units provide the following services:
Pharmaceutical services (provided by registered pharmacists and pharmacy technologists)
Food and nutrition services (managed by registered dietitians who develop general and special-diet menus and nutritional plans for individual patients)
Health information services (managed by RHIAs and RHITs)
Social work and social services (provided by licensed social workers and licensed clinical social workers)
Patient advocacy services (provided by several types of healthcare professionals, most commonly registered nurses and licensed social workers)
Environmental (housekeeping) services
Purchasing, central supply, and materials management services
Engineering and plant operations (maintenance)
In addition to clinical support services, hospitals need administrative support services to operate effectively. Administrative support services provide business management and clerical services in several key areas, including the following:
Admissions and central registration
Claims and billing (business office)
Accounting
Information services
Human resources
Public relations
Fund development
Marketing
Figure 2.4 is an example of a healthcare organizational chart showing the reporting structure for departments within the organization. The board of directors has the ultimate responsibility for the organization.
Figure 2.4 Hospital structure – example organizational chart
Source: ©AHIMA.
Other Types of Healthcare Services
Healthcare delivery is more than hospital-related care. It can be viewed as a continuum of services that cuts across care settings, including ambulatory, acute, subacute, long-term, and residential care, among others.
Managed Care Organizations
Managed care is a generic term for a healthcare reimbursement system that manages cost, quality, and access to services. Most managed care plans do not provide healthcare directly. Instead, they enter into service contracts with the physicians, hospitals, and other healthcare providers who provide medical services to enrollees in the plans.
Managed care systems control costs primarily by presetting payment amounts and restricting patient access to healthcare services through precertification and utilization review processes. (Managed care is discussed in more detail in chapter 15, Revenue Management and Reimbursement.) Managed care delivery systems also attempt to manage cost and quality by doing the following:
Implementing various forms of financial incentives for providers
Promoting healthy lifestyles
Identifying risk factors and illnesses early in the disease process
Providing patient education
There are three basic types of managed care plans. The following are the three types of managed care plans:
1. Health maintenance organizations (HMOs), which provide healthcare within a closed network
2. Preferred provider organizations (PPOs), which provide reduced costs if the plan member stays within the network but will contribute at a reduced cost if the member goes outside the network
3. Point of service (POS), which allows patients to choose between an HMO or PPO each time they have a medical encounter (NIH 2015).
Accountable Care Organizations
The Patient Protection and Affordable Care Act of 2010 has had a significant impact on physicians and hospitals, namely in the establishment of accountable care organizations (ACOs). An ACO generally describes groups of providers who are willing and able to take responsibility for improving the overall health status, care efficiency, and healthcare experience for a defined population (DeVore and Champion 2011). The law allows CMS to create ACOs by developing voluntary partnerships between hospitals and physicians to coordinate and deliver quality care to patients and allow the participating organizations to share the savings that would result from improvement of care for those Medicare populations. CMS has established three primary ACO programs whereby participating ACOs would assume the accountability for improving quality care while reducing costs for a defined Medicare patient population. The beneficiaries will be assigned to the ACO based on utilization of primary care services provided by primary care physicians. The following are the three ACO models:
1. Medicare Shared Savings program that gives Medicare fee-for-service providers an opportunity to become an ACO
2. Advance Payment ACO model designed as a supplementary incentive program for selected participants
3. Pioneer ACO model created for early adopters of coordinate care, though CMS is no longer accepting applications for this model
CMS has outlined a series of 33 quality measures in four categories (patient or caregiver experience; care coordination or patient safety; preventative health; and at-risk population) to assess the quality of care furnished by the ACO (RTI International 2015). As of 2018, there are 561 ACOs with 10.5 million beneficiaries (CMS 2018c).
Ambulatory Care
Ambulatory care is defined as the preventive or corrective healthcare provided in a practitioner’s office, a clinic, or a hospital on a nonresident (outpatient) basis. The term usually implies that patients go to locations outside their homes to obtain healthcare services and return the same day.
Ambulatory care encompasses all the health services provided to individual patients who are not residents in a healthcare facility. Such services include the educational services provided by community health clinics and public health departments. Primary care, emergency care, and ambulatory specialty care (which includes ambulatory surgery) all may be considered ambulatory care. Ambulatory care services are provided in a variety of settings, including urgent care centers, school-based clinics, public health clinics, and neighborhood and community health centers.
Current medical practice emphasizes performing healthcare services in the least costly setting possible. This change in thinking has led to decreased utilization of emergency services, increased utilization of nonemergency ambulatory facilities, decreased hospital admissions, and shorter hospital stays. The need to reduce the cost of healthcare also has led primary care physicians to treat conditions they once would have referred to specialists.
Physicians who provide ambulatory care services fall into two categories—physicians working in private practice and physicians working for ambulatory care organizations. Physicians in private practice are self-employed. They may work solo, in partnership, and in group practices set up as for-profit organizations.
Alternatively, physicians who work for ambulatory care organizations are employees of those organizations. Ambulatory care organizations include HMOs, hospital-based ambulatory clinics, walk-in and emergency clinics, hospital-owned group practices and health promotion centers, freestanding surgery centers, freestanding urgent care centers, freestanding emergency care centers, health department clinics, neighborhood clinics, home care agencies, community mental health centers, school and workplace health services, and prison health services.
Ambulatory care organizations also employ other healthcare providers, including nurses, laboratory technicians, podiatrists, chiropractors, physical therapists, radiology technicians, psychologists, and social workers.
Private Medical Practice
Private medical practices are physician-owned entities that provide primary care or medical or surgical specialty care services in a freestanding office setting. The physicians have medical privileges at local hospitals and surgical centers but are not employees of the other healthcare entities.
Medical Home
The medical home is a model of primary care physician practices that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. This has become a model for how primary care should be delivered. It is sometimes referred to as a patient-centered medical home (PCPCC 2019). Many hospitals have established medical home programs to provide the patient with a direct relationship with the provider responsible for providing their care. Between 2012 and 2016, the percentage of hospitals with a medical home grew from 18 percent to 28 percent (AHA 2018).
Hospital-Based Ambulatory Care Services
In addition to providing inpatient services, many acute-care hospitals provide various ambulatory care services such as the following.
Emergency Services and Trauma Care More than 90 percent of community hospitals in the US provide emergency services. Hospital-based emergency departments provide specialized care for victims of traumatic accidents and life-threatening illnesses. In urban areas, many also provide walk-in services for patients with minor illnesses and injuries who do not have access to regular primary care physicians.
Many physicians on the hospital staff also use the emergency care department as a setting to assess patients with problems that may either lead to an inpatient admission or require equipment or diagnostic imaging facilities not available in a private office or nursing home. Emergency services function as a major source of unscheduled admissions to the hospital.
Outpatient Surgical Services Generally, the term ambulatory surgery refers to any surgical procedure that does not require an overnight stay in a hospital. It can be performed in the outpatient surgery department of a hospital and in a freestanding ambulatory surgery center.
Outpatient diagnostic and therapeutic services are provided in a hospital or one of its satellite facilities. Diagnostic services are those services performed by a physician to identify the disease or condition from which the patient is suffering. Therapeutic services are those services performed by a physician to treat the disease or condition that has been identified.
Hospital outpatients fall into different classifications according to the types of services they receive and the location of the service. For example, emergency outpatients are treated in the hospital’s emergency or trauma care department for conditions that require immediate care. Clinic outpatients are treated in one of the hospital’s clinical departments on an ambulatory basis. Referral outpatients receive special diagnostic or therapeutic services in the hospital on an ambulatory basis, but responsibility for their care remains with the referring physician.
Observation Services An observation patient visit is a type of outpatient visit. While they may be in the same units as inpatients, they are considered an outpatient visit. Observation services are used when physicians need to determine if the patient is sick enough to need inpatient treatment.
Community-Based Ambulatory Care Services
Community-based ambulatory care services are those services provided in freestanding facilities that are not owned by or affiliated with a hospital. Such facilities can range in size from a small medical practice with a single physician to a large clinic with an organized medical staff.
Among the organizations that provide ambulatory care services are specialized treatment facilities. Examples of these community-based ambulatory care services facilities include birthing centers, cancer treatment centers, renal dialysis centers, and rehabilitation centers.
Freestanding Ambulatory Care Centers Freestanding ambulatory care centers provide emergency services and urgent care for walk-in patients. Urgent care centers provide diagnostic and therapeutic care for patients with minor illnesses and injuries. They do not serve seriously ill patients, and most do not accept patients arriving by ambulance.
Two groups of patients find these centers attractive. The first group consists of patients seeking the convenience and access of emergency services without the delays and high costs associated with using hospital services for nonurgent problems. The second group consists of patients whose insurance treats urgent care centers preferentially compared with physicians’ offices.
As they have increased in number and become familiar to more patients, many freestanding ambulatory care centers now offer a combination of walk-in and appointment services.
Freestanding Ambulatory Surgery Centers Freestanding ambulatory surgery centers generally provide surgical procedures that take anywhere from 5 to 90 minutes to perform and require less than a four-hour recovery period. Patients must schedule their surgeries in advance and be prepared to return home on the same day. Patients who experience surgical complications are sent to an inpatient facility for care.
Most ambulatory surgery centers are for-profit entities. Individual physicians, MCOs, or entrepreneurs may own them. Generally, ambulatory care centers can provide surgical services at lower cost than hospitals can because their overhead expenses are lower.
Public Health Services
The states have constitutional authority to implement public health measures, and many of them are assisted by a wide variety of federal programs and laws. The Department of Health and Human Services (HHS) is the principal federal agency that ensures health and provides essential human services. HHS has eleven operating divisions, including eight agencies in the US Public Health Services and three human services agencies. These operating divisions are responsible for a wide variety of health and human services, including prevention and conducting research for the nation. HHS coordinates closely with state and local government agencies and many HHS-funded services are provided by these agencies as well as by private-sector and nonprofit organizations.
Two units in the Office of the Secretary of HHS are important to public health—the Office of the Surgeon General of the United States and the Office of Disease Prevention and Health Promotion (ODPHP). The surgeon general is appointed by the president of the United States and provides leadership and authoritative, science-based recommendations about the public’s health. He or she has responsibility for the public health service (PHS) workforce and the ODPHP provides an analysis and leadership role for health promotion and disease prevention. Figure 2.5 shows the agencies that exist within HHS.
Figure 2.5 Department of Health and Human Services agencies
Administration for Children and Families (ACF)- ACF promotes the economic and social well-being of families, children, individuals, and communities.
Administration for Community Living (ACL)- ACL increases access to community support and resources for the unique needs of older Americans and people with disabilities.
Agency for Healthcare Research and Quality (AHRQ)- AHRQ’s mission is to produce evidence to make healthcare safer, higher quality, more accessible, equitable, and affordable, and to work within HHS and with other partners to make sure that the evidence is understood and used.
Agency for Toxic Substances and Disease Registry (ATSDR)- ATSDR prevents exposure to toxic substances and the adverse health effects and diminished quality of life associated with exposure to hazardous substances from waste sites, unplanned releases, and other sources of environmental pollution.
Centers for Disease Control and Prevention (CDC)- CDC, part of the US Public Health Service (PHS) protects the public health of the nation by providing leadership and direction in the prevention and control of diseases and other preventable conditions, and responding to public health emergencies.
Centers for Medicare & Medicaid Services (CMS)- CMS combines the oversight of the Medicare program, the federal portion of the Medicaid program and State Children’s Health Insurance Program, the Health Insurance Marketplace, and related quality assurance activities.
Food and Drug Administration (FDA)- FDA, part of the PHS ensures food is safe, pure, and wholesome; human and animal drugs, biological products, and medical devices are safe and effective; and electronic products that emit radiation are safe.
Health Resources and Services Administration (HRSA)- HRSA, part of the PHS provides healthcare to people who are geographically isolated or economically or medically vulnerable.
Indian Health Service (IHS)- IHS, part of the PHS provides American Indians and Alaskan Natives with comprehensive health services by developing and managing programs to meet their health needs.
National Institutes of Health (NIH)- NIH, part of the PHS, supports biomedical and behavioral research within the US and abroad, conducts research in its own laboratories and clinics, trains promising young researchers, and promotes collecting and sharing medical knowledge.
Substance Abuse and Mental Health Services Administration (SAMHSA)- SAMHSA, part of the PHS, improves access and reduces barriers to high-quality, effective programs and services for individuals who suffer from or are at risk for addictive and mental disorders, as well as for their families and communities.
Source: Adapted from HHS 2019.
Home Healthcare Services
Home healthcare is the fastest-growing sector to offer services for recipients. Home healthcare is limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment, supplies and other services (CMS 2017a). The primary reason for this is increased economic pressure from third-party payers who want patients released from the hospital more quickly than they were in the past. Moreover, patients generally prefer to be cared for in their own homes. In fact, most patients prefer home care, no matter how complex their medical problems.
In 1989, Medicare rules for home care services were clarified to make it easier for Medicare beneficiaries to receive them. Patients are eligible to receive home health services from a qualified Medicare provider when they are homebound, under the care of a specified physician who will establish a home health plan, and when they need physical or occupational therapy, speech therapy, or intermittent skilled nursing care.
Skilled nursing care is defined as technical procedures, such as tube feedings and catheter care, and skilled nursing observations. Intermittent is defined as up to 28 hours per week for nursing care and 35 hours per week for home health aide care. Many hospitals have formed their own home healthcare agencies to increase revenues and at the same time to enable them to discharge patients from the hospital earlier.
Voluntary Agencies
Voluntary agencies provide healthcare and healthcare planning services, usually at the local level and to low-income patients. Their services range from giving free immunizations to offering family planning counseling. Funds to operate such agencies come from a variety of sources, including local or state health departments, private grants, and funds from different federal bureaus.
One common example of a voluntary agency is the community health center. Sometimes called neighborhood health centers, community health centers offer comprehensive, primary healthcare services to patients who otherwise would not have access to them. Often patients pay for these services on a sliding scale based on income or according to a flat rate, discounted fee schedule supplemented by public funding.
Some voluntary agencies offer specialized services such as counseling for battered and abused women. Typically, these are set up within local communities. An example of a voluntary agency that offers services on a much larger scale is the Red Cross.
Subacute Care
Patients needing ongoing rehabilitative care or treatment using advanced technology sometimes are eligible to receive subacute care. Subacute care offers patients access to constant nursing care while recovering at home. In the past, patients could receive comprehensive rehabilitative care only while in the hospital. Today, however, the availability of subacute-care services allows patients to optimize their functional gain in a familiar and more comfortable environment. In essence, subacute care in most IDNs emphasizes patient independence. The patient is given an individualized care plan developed by a highly trained team of healthcare professionals. Patients considered appropriate for subacute care are those recovering from stroke, cardiac surgery, serious injury, amputation, joint replacement, or chronic wounds.
Long-Term Care
In general, long-term care is the healthcare rendered in a non-acute-care facility to patients who require inpatient nursing and related services for more than 30 consecutive days. Skilled nursing facilities, nursing homes, and rehabilitation hospitals are the principal facilities that provide long-term care. Rehabilitation hospitals provide recuperative services for patients who have suffered strokes and traumatic injuries as well as other serious illnesses. Specialized long-term care facilities serve patients with chronic respiratory disease, permanent cognitive impairment, and other incapacitating conditions.
Long-term care encompasses a range of health, personal care, social, and housing services provided to people of all ages with health conditions that limit their ability to carry out normal daily activities without assistance. People who need long-term care have many different types of physical and mental disabilities. Moreover, their need for the mix and intensity of long-term care services can change over time.
Long-term care is mainly rehabilitative and supportive rather than curative. Moreover, healthcare workers other than physicians can provide long-term care in the home or in residential or institutional settings.
Long-Term Care in the Continuum of Care
The availability of long-term care is one of the most important health issues in the United States today. There are two principal reasons for this. First, people are living longer today than they did in the past as a result of advances in medicine and healthcare practices. The number of people who survive previously fatal conditions is growing, and more and more people with chronic medical problems can live reasonably normal lives. Second, there was an explosion in the birthrate after World War II. Children born during that period (1946 to 1964), the “baby-boomer” generation, are today in their late 1950s to 1970s. These factors combined mean that the need for long-term care will only increase in the years to come.
As discussed earlier, healthcare is now viewed as a continuum of care. In the case of long-term care, the patient’s continuum of care may have begun with a primary provider in a hospital and then continued with home care and eventually care in a skilled nursing facility. The patient’s care is coordinated from one care setting to the next.
Moreover, the roles of the different care providers along the patient’s continuum of care are continuing to evolve. Health information managers play a key part in providing consultation services to long-term care facilities with regard to developing systems to manage information from a diverse number of healthcare providers.
Delivery of Long-Term Care Services
Long-term care services are delivered in a variety of settings, including skilled nursing facilities or nursing homes, residential care facilities, hospice programs, and adult day-care programs.
Skilled Nursing Facilities or Nursing Homes The most important providers of formal, long-term care services are nursing homes, or skilled nursing facilities (SNFs), which provide medical, nursing, or rehabilitative care, in some cases, around the clock. Most SNFs have residents over the age 65 and provide care for those who can no longer live independently.
Many SNFs are owned by for-profit organizations. However, SNFs also may be owned by not-for-profit groups as well as local, state, and federal governments. In recent years, there has been a decline in the total number of nursing homes in the US, but an increase in the number of nursing home beds.
Nursing homes are no longer the only option for patients needing long-term care. Various factors play a role in determining which type of long-term care facility is best for a particular patient, including cost, access to services, and individual needs.
Residential Care Facilities New living environments that are more homelike and less institutional are the focus of much attention in the current long-term care market. Residential care facilities now play a growing role in the continuum of long-term care services. Having affordable and appropriate housing available for elderly and disabled people can reduce the level of need for institutional long-term care services in the community. Institutionalization can be postponed or prevented when the elderly and disabled live in safe, accessible settings where assistance with daily activities is available.
Hospice Programs Hospice care is provided mainly in the home to patients who are diagnosed with a terminal illness with a limited life expectancy of six months or less. Hospice is based on a philosophy of palliative care imported from England and Canada that holds that during the course of terminal illness, the patient should be able to live life as fully and as comfortably as possible, but without artificial or mechanical efforts to prolong life. Hospice care is not focused on cure. It is palliative; focusing on pain relief, comfort, and enhanced quality of life for the terminally ill.
In the hospice approach, the family is the unit of treatment. An interdisciplinary team provides medical, nursing, psychological, therapeutic, pharmacological, and spiritual support during the final stages of illness, at the time of death, and during bereavement. The main goals are to control pain, maintain independence, and minimize the stress and trauma of death.
Hospice services have gained acceptance as an alternative to hospital care for the terminally ill. The number of hospices is likely to continue to grow because this philosophy of care for people at the end of life has become a model for the nation.
Adult Day-Care Programs Adult day-care programs offer a wide range of health and social services to elderly persons during the daytime hours. Adult day-care services are usually targeted to elderly members of families in which the regular caregivers work during the day. Many elderly people who live alone also benefit from leaving their homes every day to participate in programs designed to keep them active. The goals of adult day-care programs are to delay the need for institutionalization and to provide respite for caregivers.
Data on adult day-care programs are still limited, but there were about 5,000 programs in 2015 providing services to 260,000 participants in a variety of programs (NADSA 2019).
Biomedical and Technological Advances in Medicine
Advances in technology in the healthcare industry have made it possible for care to be delivered to patients closer to their home or even in their home. The sections that follow will explore and describe the benefits of telehealth technologies and electronic health records and health data and the effects they have made on the delivery of healthcare.
Telehealth
The Health Resources and Services Administration (HRSA) of HHS defines telehealth as the use of electronic information and telecommunications technologies to support and promote long-distance clinical healthcare, patient and professional health-related education, public health, and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications (ONCHIT 2019). Figure 2.6 shows the types of telehealth applications.
Figure 2.6 Types of telehealth applications
Source: Adapted from ONCHIT 2019.
Electronic Health Records and Health Data
Electronic health records (EHRs) and the ability to record, capture, and manipulate health data have had a tremendous impact on the delivery of healthcare. Big data refers to large amounts of data that are collected from sources and then processed and used for analytics. Collected and analyzed health data have multiple benefits including the following:
Reducing healthcare costs
Predicting epidemics
Avoiding preventable deaths
Improving quality of life
Reducing healthcare waste
Improving efficiency and quality of care
Developing new drugs and treatments (Banova, 2018)
The American Recovery and Reinvestment Act of 2009, the Patient Protection and Affordable Care Act, and other quality-of-care programs represent the movement from a volume-based delivery model to a data-driven, value-based approach. Data collected from EHRs is utilized to measure outcomes performance that is directly tied to reimbursement. In addition, data collected from EHRs is utilized by clinical researchers to develop new treatments for common health problems. The collection and evaluation of data in a centralized system can identify a viral or bacterial infection to give insights into how widespread an outbreak is.
Ninety-six percent of hospitals in the United States have a federally tested and certified EHR program (Reisman 2017). The next challenge for the use of EHRs is ensuring interoperability. Interoperability refers to more than the exchange of information; it requires that the data exchanged are usable. This means that the receiving system must be able to interpret the data. With the variety of government certified EHR products in use, each one has its own clinical terminologies, technical specifications, and functional capabilities. This makes it very difficult to create one standard interoperability format to share data.
Artificial Intelligence
The increasing availability of healthcare data and rapid development of big data analytic methods have made possible the recent successful applications of artificial intelligence (AI) in healthcare. AI is the ability of a computer program or machine to think and learn. AI uses sophisticated algorithms to learn trends or features from large volumes of health data to make judgments. It can be equipped with learning and self-correcting abilities to improve accuracy based on feedback. AI is not meant to replace the physician, but to assist the physician in making better clinical decisions or replace human judgment in functional areas of healthcare such as radiology (Jiang et al. 2017).
Before AI systems can be successfully utilized, they have to be trained through data that are generated from clinical activities so they can learn the group of subjects and associations. There are two major categories of AI: machine learning (ML) and natural language processing (NLP). Machine learning analyzes structured data such as imaging and genetic results, then attempts to cluster the patient’s traits or infer the probability of the disease outcomes (Jiang et al. 2017). NLP methods extract information from unstructured data such as clinical notes to supplement the structured data. NLP focuses on turning the text into machine-readable structured data that can be analyzed by ML techniques.
One of the most common uses of AI in healthcare has been the use of speech recognition. It is also being used in radiology to assist in the diagnostic process by analyzing images such as MRIs, x-rays, and CT scans and providing feedback on what it detects. AI is being utilized in medical monitoring devices to transform them into smart medical devices. Traditional medical devices monitor and record data to be reviewed by a clinician at a later time. Smart medical devices can analyze and respond to the recorded data. For example, an insulin pump utilizing AI can predict how much insulin the patient will need and when they will need it rather than just responding to spikes in blood sugar.
Policy Making and Healthcare Delivery
The American healthcare system is a patchwork of independent and governmental entities that provide healthcare services to those in need. Institutions ranging from not-for-profits, for-profits, and governmental agencies provide not only services but also policy on how Americans are to receive and pay for their healthcare.
The government’s role in healthcare services is extensive from the federal level down to the county and local levels. By setting policies on how healthcare is provided, delivered, and reimbursed, government agencies have a significant impact on our healthcare delivery system.
The following sections list five ways that healthcare policies affect the American people. All the policies are dedicated to providing the best services in a system that is constrained by increasing costs generally at the expense of access and quality.
Healthy People 2020
Launched in December 2010 by the Office of Disease Prevention and Heath Promotion of HHS, Healthy People 2020 sets out a plan to improve the nation’s health with a vision of “a society in which all people live long, healthy lives” (Healthy People 2015). Healthy People provides users with access to data on changes in the health status of the US population and informs of each new decade’s goals and objectives. Communities may adopt the Healthy People goals and objectives and may alter them to set the priorities for their region and population groups. Since it was launched, Healthy People has noted significant achievements in reducing causes of death such as heart disease and cancer; reducing infant and maternal mortality; reducing risk factors like tobacco smoking, hypertension, and elevated cholesterol; and increasing childhood vaccinations (Healthy People 2019a).
Healthy People 2020 is the third initiative (starting with Healthy People 2000) since its inception 30 years ago. The overall goals of Healthy People 2020 are to do the following:
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death
Achieve health equity, eliminate disparities, and improve the health of all groups
Create social and physical environments that promote good health for all
Promote quality of life, healthy development, and healthy behaviors across all life stages (Healthy People 2015)
One topic area of Healthy People 2020 is social determinants of health. Social determinants of health (SDOH) are conditions such as environment and age that impact a wide range of health, functioning, and quality-of-life outcomes and risks. Examples of social determinants include:
Availability of resources to meet daily needs
Access to educational, economic, and job opportunities
Availability of community-based resources
Exposure to crime, violence, and social disorder
Socioeconomic conditions
Language and literacy
Access to mass media and emerging technologies
Culture (Healthy People 2019b)
Healthy People 2020 established a place-based organizing framework reflecting five determinants areas of SDOH. This framework reflects the importance of the relationship between how population groups experience “place” and the impact of “place” on health. This includes both social and physical determinants. The five key determinants are economic stability, education, social and community context, health and healthcare, and neighborhood and built environment (Healthy People 2019b). Figure 2.7 shows the five key social determinants of health, including economic stability, education, social and community context, health and healthcare and neighborhood and built environment.
Figure 2.7 Healthy People 2020 five key social determinants of health
Source: Adapted from Healthy People 2019b.
Healthy People 2020 also recognizes that health information technology and health communication are integral parts of the implementation process of the initiative.
The next phase of Healthy People is Healthy People 2030. The framework for the Healthy People 2030 initiative has been developed. HHS solicited comments on the proposed framework and these comments were used to finalize the framework. The Healthy People 2030 framework was approved by the HHS Secretary in June 2018. The overarching goals of the framework include the following:
Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury, and premature death
Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all
Create social, physical, and economic environments that promote attaining full potential for health and well-being for all
Promote healthy development, healthy behaviors and well-being across all life stages
Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all (Healthy People 2019a)
The ultimate goal of Healthy People 2020 is to develop a feasible, public health information technology infrastructure in conjunction with the national health information network.
The National Institutes of Health
The National Institutes of Health (NIH), part of HHS, is the nation’s medical research agency. The mission of the NIH is to seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability (NIH 2017). To support their mission, the NIH invests over $30 billion in taxpayer dollars in biomedical research.
The goals of the agency are to do the following:
Foster fundamental creative discoveries, innovative research strategies, and their applications as a basis for ultimately protecting and improving health
Develop, maintain, and renew scientific human and physical resources that will ensure the nation’s capability to prevent disease
Expand the knowledge base in medical and associated sciences to enhance the nation’s economic well-being and ensure a continued high return on the public investment in research
Exemplify and promote the highest level of scientific integrity, public accountability, and social responsibility in the conduct of science
Surgical procedures were performed before the development of anesthesia, requiring surgeons to work quickly on conscious patients to minimize the risk and pain. The availability of anesthesia made it possible for surgeons to develop more advanced surgical techniques. Ether, nitrous oxide, and chloroform were used as anesthetics by the middle of the 19th century. By the 1860s, the physicians who treated the casualties of the American Civil War on both sides had access to anesthetic and painkilling drugs.
During the late 1800s, significant improvements in healthcare were being made. In 1885, Louis Pasteur developed a vaccine that prevented rabies. Joseph Lister was the first to apply Pasteur’s research to the treatment of infected wounds. His discovery was called the antiseptic principle, which helped reduce the mortality rate in Lister’s own hospital. At the end of the 19th century, German physicist Wilhelm Rontgen was studying the effects of passing an electrical current through gases at low pressure. While doing this, he accidentally discovered x-rays (The Scientist 2011).
Diagnostic radiology and radiation therapy have undergone huge advances in the past 50 years. In 1971 an imaging modality called computed tomography (CT) was first invented. The first CT scanners were used to create images of the skull. Whole-body scanners were introduced in 1974. In the 1980s, another powerful diagnostic tool was added—magnetic resonance imaging (MRI). An MRI is a noninvasive technique that uses magnetic and radio-frequency fields to record images of soft tissues.
Surgical advances have been remarkable as well. Cardiac bypass surgery and joint replacement surgery were developed in the 1970s. Organs are now successfully transplanted, and artificial organs are being tested. New surgical techniques have included the use of lasers in ophthalmology, gynecology, and urology. Microsurgery is now a common tool in the reconstruction of damaged nerves and blood vessels.
The future of surgery could include physicians using advanced robots, virtual reality, augmented reality, and 3D printing and simulations in preoperative planning and education (The Medical Futurist 2017).
Today, it is human genetics and progress toward sequencing the human genome that promise to change the healthcare paradigm. New research on cellular and molecular changes underlying disease processes will necessitate new approaches to diagnosis and treatment.
The current paradigm for treating disease is to meet with the patient, diagnose the patient’s symptoms, and prescribe therapy to treat them. The hope is that genetic medicine will enable the provider to identify gene patterns that underlie the process of cellular dysfunction that leads to injury before even meeting with the patient. Thus, diseases will be diagnosed much earlier, enabling physicians to provide treatment to stop or slow the disease process.
The study of cell-based technologies is controversial. Cell-based technologies include the following:
Tissue engineering, which involves the use of biomaterials to develop new tissue and even whole organs with or without transplanting cells
Human embryonic stem cells or adult stem cells used for transplantation and in regenerative medicine
Gene therapy or cell transplantation
The National Human Genome Research Institute (NHGRI) was established in 1989 to carry out the role of the NIH in the International Human Genome Project (HGP). The HGP began in 1990 to map the human genome. Since the completion of the human genome sequence in 2003, the NHGRI expanded its role to apply genome technologies to the study of specific diseases (NHGRI 2018). In fall 2020, NHGRI will launch its newest strategic plan aimed at accelerating scientific and medical breakthroughs. Through its strategic plan, the NHGRI will prioritize discussions in emerging areas of genomics that are not well defined and that are not specific to particular diseases or physiological systems. These include broadly applicable areas such as genomic technology development; using genomic information in patient care; and the ethical, legal, and social implications of genomics.
National Academy of Medicine Reports
The National Academy of Medicine (NAM), formerly known as the Institute of Medicine, was established in 1970 as a nongovernmental agency to provide unbiased advice to decision makers and the public. NAM has written over 1,000 reports since 1970. A selection of quintessential publications dealing with the public’s health include the following publications:
To Error is Human (1999) reported that as many as 98,000 people die each year from preventable medical errors (IOM 1999).
Crossing the Quality Chasm (2001) identified gaps in the delivery of patient care services resulting from a complex medical system as well as the rapid advancement in medical knowledge (IOM 2001).
Envisioning a National Health Care Quality Report (2001) addressed the collection, measurement, and analysis of quality data (Hurtado et al. 2001).
Leadership by Example (2002) addressed the duplication and contrasting approaches to performance measures by the six major governmental healthcare programs that serve nearly 100 million Americans (IOM 2002).
Priority Areas for National Action (2003) recognized priorities from earlier reports and suggested a framework for action (IOM 2003).
Health IT and Patient Safety (2012) stated that the improvement in safety of health IT is essential and can help improve healthcare providers’ performance, improve communication between patients and providers, and enhance patient safety (IOM 2012).
Human Genome Editing: Science, Ethics and Governance (2017) considered important questions about the human application of genome editing.
Optimizing Strategies for Clinical Decision Support (2017) identified the need for a continuously learning health system driven by the seamless and rapid generation, processing, and practical application of the best available evidence for clinical decision-making.
Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care (2018) identified data exchanges determined to be critical to achieving interoperability and identified the key characteristics of information exchange involved in health and healthcare.
Centers for Disease Control and Prevention
Founded in 1946, the Centers for Disease Control and Prevention (CDC) is the leading federal agency charged with protecting the public health and safety through the control and prevention of disease, injury, and disability. The CDC leads the nation in the following services:
Detecting and responding to diseases and conditions (attention deficit hyperactivity disorder, sexually transmitted diseases, cancer, heart disease, diabetes, flu)
Promoting healthy living (adolescents and school health, food safety, tobacco and alcohol use, overweight and obesity, vaccines and immunizations)
Providing information for travelers’ health (destinations, travel notices, find a clinic)
Educating for emergency preparedness (natural disasters and severe weather, recent outbreaks and incidents, bioterrorism, chemical emergencies, radiation emergencies, mass casualties)
The CDC headquarters is in Atlanta, GA and there are 10 additional locations in the United States. With over 14,000 employees, the CDC collects, analyzes, and creates national statistical databases and publishes papers on important health issues (CDC 2019).
Local, State, and Federal Policies
All levels of government create policies affecting the nation’s healthcare. At the local and community level, leaders decide where public funds will finance community health centers and municipal hospitals, which provide care regardless of the patient’s ability to pay.
At the state level, decisions on access, eligibility, and level of treatments for Medicaid recipients, where state and federal dollars will be spent on items like tobacco cessation and gambling addiction centers (for those states with casinos), and how to provide services to people with special needs, as well as funding for mental health facilities are a large component of most state budgets.
At the federal level, six agencies provide healthcare to over 100 million Americans (Medicare, Medicaid, State Children’s Health Insurance Program [SCHIP], Veterans Health Administration [VHA], TRICARE, and Indian Health Service [IHS]). All three branches of government have input on the cost, access, and quality of care provided to Americans through these federal agencies as well as the various policy-making institutions that provide carefully considered input to the decision makers.
Unfortunately, the American healthcare system was not developed from a master plan but is instead a patchwork quilt of measures passed not from thought as to how they would affect the whole, but rather based on ideology. Much attention today is focused on the cost of healthcare often at the expense of patient access and the quality of care provided.
Patient-Centered Outcomes Research Institute
The Patient-Centered Outcomes Research Institute (PCORI) was created in 2010 from the passage of the Patient Protection and Affordable Care Act (ACA) as a nonprofit, nongovernmental organization mandated to improve the quality and applicability of evidence available to help all stakeholders (patients, caregivers, clinicians, employers, insurers, and policy makers) to make knowledgeable healthcare choices. While PCORI is not the first organization focusing on patient-centered care, it is the largest single research funder that has comparative effectiveness research (CER) as its main focus and incorporates patients and other stakeholders throughout the process more consistently and intensively than others have before. In its strategic plan, PCORI has outlined the following three overarching goals:
1. Substantially increase the quantity, quality, and timeliness of useful, trustworthy information available to support health decisions
2. Speed the implementation and use of patient-centered outcomes research (PCOR) evidence.
3. Influence clinical and healthcare research funded by others to be more patient centered (PCORI 2017)
Modern Healthcare Delivery in the United States
Until World War II, most healthcare was provided in the home. Quality in healthcare services was considered a product of appropriate medical practice and oversight by physicians and surgeons. Even the minimum standards used to evaluate the performance of hospitals were based on factors directly related to the composition and skills of the hospital medical staff.
The 20th century was a period of tremendous change in American society. Advances in medical science promised better outcomes and increased the demand for healthcare services. But medical care has never been free. Even in the best economic times, many Americans have been unable to take full advantage of what medicine has to offer because they cannot afford it.
Concern over access to healthcare was especially evident during the Great Depression of the 1930s. During the Depression, America’s leaders were forced to consider how the poor and disadvantaged could receive the care they needed. Before the Depression, medical care for the poor and elderly had been handled as a function of social welfare agencies. However, during the 1930s, few people were able to pay for medical care. The problem of how to pay for the healthcare needs of millions of Americans became a public and governmental concern. Working Americans turned to prepaid health plans to help them pay for healthcare, but the unemployed and the unemployable needed help from a different source.
During the 20th century, Congress passed many pieces of legislation that had a significant impact on the delivery of healthcare services in the United States.
Social Security Act of 1935
The Great Depression revived the dormant social reform movement in the United States as well as more radical currents in American politics. The Depression also brought to power the Democratic administration of Franklin D. Roosevelt, which was more willing than any previous administration to involve the federal government in the management of economic and social welfare.
Although old-age pension and unemployment insurance bills were introduced into Congress soon after his election, Roosevelt refused to give them his strong support. Instead, he created a program of his own and appointed a Committee on Economic Security to study the issue comprehensively and report to Congress in January 1935.
Sentiment in favor of health insurance was strong among members of the Committee on Economic Security. However, many members of the committee were convinced that adding a health insurance amendment would spell defeat for the entire Social Security legislation. Ultimately, the Social Security bill included only one reference to health insurance as a subject that the new Social Security Board might study. The Social Security Act was passed in 1935.
Public Law 89–97 of 1965
In 1965, passage of a number of amendments to the Social Security Act brought Medicare and Medicaid into existence. The two programs have greatly changed how healthcare organizations are reimbursed. Recent attempts to curtail Medicare and Medicaid spending continue to affect healthcare organizations.
Medicare (Title XVIII of the Social Security Act) is a federal program that provides healthcare benefits for people age 65 and older who are covered by Social Security. The program was inaugurated on July 1, 1966. Over the years, amendments have extended coverage to individuals who are not covered by Social Security but are willing to pay a premium for coverage, to the disabled, and to those suffering from end-stage renal disease (ESRD).
The companion program, Medicaid (Title XIX of the Social Security Act), was established at the same time to support medical and hospital care for persons classified as medically indigent. Originally targeting recipients of public assistance (primarily single-parent families and the aged, blind, and disabled), Medicaid has expanded to additional groups so that it now targets poor children, the disabled, pregnant women, and very poor adults, including those age 65 and older.
Today, Medicaid is a federally mandated program that provides healthcare benefits to low-income people and their children. Medicaid programs are administered and partially paid for by individual states. Medicaid is an umbrella for 50 different state programs designed specifically to serve the poor. Beginning in January 1967, Medicaid provided federal funds to states on a cost-sharing basis to ensure welfare recipients would be guaranteed medical services. Coverage of four types of care was required: inpatient and outpatient services, other laboratory and x-ray services, physician services, and nursing facility care for persons over 21 years of age.
Many enhancements have been made in the years since Medicaid was enacted. Services now include family planning and 31 other optional services such as prescription drugs and dental services. With few exceptions, recipients of cash assistance are automatically eligible for Medicaid. Medicaid also pays the Medicare premium, deductible, and coinsurance costs for some low-income Medicare beneficiaries. More information on Medicaid can be found in chapter 15, Revenue Management and Reimbursement.
Medicaid spending has also increased 13.9 percent over that time period. The increase in spending is attributed to the growth in enrollment, increased provider rates, increased prescription costs, and other costs spread out over the healthcare system (Kaiser Family Foundation 2015). This represented a peak in enrollment. Since 2015, enrollment growth has slowed, in part, to the tapering of ACA enrollment growth (Kaiser Family Foundation 2019).
Public Law 92–603 of 1972
To curtail Medicare and Medicaid spending, additional amendments to the Social Security Act were instituted in 1972. Public Law 92–603 required concurrent review for Medicare and Medicaid patients. It also established the professional standards review organization (PSRO) program to implement concurrent review. PSROs performed professional review and evaluated patient care services for necessity, quality, and cost-effectiveness.
Utilization review (UR) is the process of determining whether the medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified in the organization’s utilization management plan. UR was a mandatory component of the original Medicare legislation. Medicare required hospitals and extended care facilities, which are facilities licensed by applicable state or local law to offer room and board, skilled nursing by a full-time RN, intermediate care, or a combination of levels on a 24-hour basis over a long period of time. Extended care facilities are required to establish a plan for UR as well as a permanent utilization review committee. The goal of the UR process is to ensure the services provided to Medicare beneficiaries are medically necessary.
Utilization Review Act of 1977
In 1977, the Utilization Review Act made it a requirement for hospitals to conduct continued-stay reviews for Medicare and Medicaid patients. Continued-stay reviews determine whether it is medically necessary for a patient to remain hospitalized. This legislation also included fraud and abuse regulations. More information on fraud and abuse can be found in chapter 16, Fraud and Abuse Compliance.
Peer Review Improvement Act of 1982
In 1982, the Peer Review Improvement Act redesigned the PSRO program and renamed the agencies peer review organizations (PROs). At that time, hospitals began to review the medical necessity and appropriateness of certain admissions even before patients were admitted. PROs were given a new name in 2002 and now are called quality improvement organizations (QIOs). They currently emphasize quality improvement processes. Each state and territory, as well as the District of Columbia, now has its own QIO. The mission of the QIOs is to ensure the quality, efficiency, and cost-effectiveness of the healthcare services provided to Medicare beneficiaries in its locale.
Tax Equity and Fiscal Responsibility Act of 1982
In 1982, Congress passed the Tax Equity and Fiscal Responsibility Act (TEFRA). TEFRA required extensive changes in the Medicare program. Its purpose was to control the rising cost of providing healthcare services to Medicare beneficiaries. Before this legislation was passed, healthcare services provided to Medicare beneficiaries were reimbursed on a retrospective, or fee-based, payment system. TEFRA required the gradual implementation of a prospective payment system (PPS) for Medicare reimbursement.
In a retrospective payment system, a service is provided, a claim for payment for the service is made, and the healthcare provider is reimbursed for the cost of delivering the service. In a PPS, a predetermined level of reimbursement is established before the service is provided. More information on PPSs can be found in chapter 15, Revenue Management and Reimbursement.
Public Law 98–21 of 1983
The PPS for acute hospital care (inpatient) services was implemented on October 1, 1983, according to Public Law 98–21. Under the inpatient PPS, reimbursement for hospital care provided to Medicare patients is based on diagnosis-related groups (DRGs). Each case is assigned to a DRG based on the patient’s diagnosis at the time of discharge. For example, under the inpatient PPS, all cases of viral pneumonia would be reimbursed at the same predetermined level of reimbursement no matter how long the patients stayed in the hospital or how many services they received. PPSs for other healthcare services provided to Medicare beneficiaries have been gradually implemented since 1983.
Health Insurance Portability and Accountability Act of 1996
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses issues related to the portability of health insurance after leaving employment, establishment of national standards for electronic healthcare transactions, and national identifiers for providers, health plans, and employers. A portion of HIPAA addressed the security and privacy of health information by establishing privacy standards to protect health information and security standards for electronic healthcare information. HIPAA privacy and security standards are covered in chapter 9, Data Privacy and Confidentiality, and chapter 10, Data Security. Another provision of HIPAA was the creation of the Healthcare Integrity and Protection Data Bank (HIPDB) to combat fraud and abuse in health insurance and healthcare delivery. A purpose of the HIPDB is to inform federal and state agencies about potential quality problems with clinicians, suppliers, and providers of healthcare services. The American Recovery and Reinvestment Act (ARRA) includes important changes in HIPAA privacy and security standards that are also discussed in chapters 9 and 10.
American Recovery and Reinvestment Act of 2009
The American Recovery and Reinvestment Act of 2009 (ARRA) is considered one of the major health information technology laws that provided stimulus funds to the US economy in the midst of a major economic downturn. A substantial portion of the bill, Title XIII of the Act entitled the Health Information Technology for Economic and Clinical Health (HITECH) Act, allocated funds for implementation of a nationwide health information exchange and implementation of electronic health records. The bill provides for investment of billions of dollars in health information technology and incentives to encourage physicians and hospitals to use information technology; $19.2 billion was dedicated to implementing and supporting health information technology. ARRA requires the government to take a leadership role in developing standards for exchange of health information nationwide, strengthens federal privacy and security standards, and established the Office of the National Coordinator for Health Information Technology (ONC) as a permanent office (Rode 2009). Four major components of the bill include: meaningful use (that providers are using certified EHRs to improve patient outcomes); EHR standards and certifications; regional extension centers (used to assist providers with selection and implementation of EHRs); and breach notification guidance. Though challenged in court, the US Supreme Court upheld the law in a 6–3 decision. Meaningful use was changed in 2018 to the Promoting Interoperability incentive program. EHR incentive programs are discussed in chapter 16, Fraud and Abuse Compliance.
Patient Protection and Affordable Care Act of 2010
The Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010, and is the most significant healthcare reform legislation of the first decade of the 21st century. The Kaiser Family Foundation summarizes the following major provisions of the ACA:
The Medicaid expansion to 138 percent of the federal poverty level ($15,415 for an individual and $31,809 for a family of four in 2012) for individuals under age 65
The creation of health insurance exchanges through which individuals who do not have access to public coverage or affordable employer coverage will be able to purchase insurance with premium and cost-sharing credits available to some people to make coverage more affordable
New regulations on all health plans that will prevent health insurers from denying coverage to people for any reason, including health status, and from charging higher premiums based on health status and gender
The requirement that most individuals have health insurance beginning in 2014 with tax penalties for those without insurance
The penalties to employers that do not offer affordable coverage to their employees, with exceptions for small employers (Kaiser Family Foundation 2012)
Since the ACA became law, the number of uninsured individuals in the United States has declined from 49 million in 2010 to 29 million in 2015 (JAMA 2016). The law’s major coverage provisions combined with financial assistance for low- and moderate-income individuals to purchase their coverage and generous federal support for states that expand their Medicaid programs to cover more low-income adults have all contributed to the gains in health coverage. The law’s provision allowing young adults to stay on a parent’s plan until age 26 years has also played a contributing role, covering an estimated 2.3 million people after it took effect in late 2010 (JAMA 2016).
Since 2017, a number of proposals have been presented to repeal and replace the ACA. One includes the repeal of a 2.3 percent excise tax on the sale of certain medical devices by manufacturers. This tax was passed on to purchasers of devices, mainly hospitals and physicians, which filtered down to consumers. An executive order signed by President Trump on January 20, 2017, authorized the Secretary of the Department of Health and Human Services to repeal this tax at his discretion (Shi and Singh 2019).
Real World Case 2.1
Steve is a 35-year-old, single male who lived in a one-bedroom apartment in a safe neighborhood. Steve worked as a maintenance technician for a local mill. Steve’s job provided health insurance and he rarely needed to use it. Steve smoked half a pack of cigarettes each day and drank socially a few times a month.
One afternoon, Steve’s company notified him that it was laying off more than one hundred employees, including him. Though he was devastated about losing his job, Steve was grateful that he had some savings that he could use for rent and other bills, in addition to the unemployment checks he would receive for a few months. For the next six months, Steve searched aggressively for a job but was unable to find one. With his savings depleted, he was not able to make ends meet, and he was evicted from his apartment. His self-esteem plummeted and he became depressed.
Steve stayed with various family members and friends and was able to pick up some odd jobs to make some money. However, his drinking and anger got worse and his hosts asked him to leave. When he ran out of people to call, he started sleeping at the park. One night when Steve was drunk, he fell and cut his shin. The injury became red and filled with pus. Steve was embarrassed about his situation and didn’t want anyone to see him. But when he developed a fever and pain, he decided to walk to the nearest emergency department. He saw a provider who diagnosed him with cellulitis, a common but potentially serious bacterial skin infection, and gave him a copy of the patient instructions that read “discharge to home” and a prescription for antibiotics. Steve could not afford the entire prescription, but he was able to purchase half the tablets.
Steve began staying at a shelter. Each morning he had to leave the shelter by 6 am, and he walked the streets during the day and panhandled for money to buy alcohol. One day two men jumped Steve, kicked him repeatedly, and stole his backpack. A bystander called 911 and he was taken to the same emergency department where he had sought treatment for the shin injury. Again, the providers didn’t screen him for homelessness, and he was discharged back to “home.”
A few days later, an outreach team from a local nonprofit organization introduced themselves to Steve and asked if he was ok. He did not engage in conversation with them. They offered him a sandwich, a drink, and a blanket, which he took without making eye contact. The outreach team visited him over the next several days and noticed his shortness of breath and the cut on his leg.
After a couple of weeks, Steve began to trust the outreach team and agreed to go to the organization’s medical clinic. The clinic provided primary care and behavioral health services through scheduled and walk-in appointments. Steve said the providers there treated him like a real person. He was able to have regular appointments with a therapist and began working on his depression and substance abuse. A year later, his health has improved. He is sober and working with a case manager to find housing.
Real-World Case 2.2
A municipal medical center in a city of 100,000 residents decided that they needed to diversify if they were going to survive the ups and downs of the economy. The board of directors met with the chief of the medical staff to determine the best course of action. They mutually decided to emphasize a cradle-to-grave approach by acquiring a few select physician practices and a local nursing home, starting a home health agency, and creating a hospice unit within the medical center. The board then decided to link all new acquisitions to the medical center’s existing electronic health record (EHR) but ran into a problem with patient identification for health record purposes. The issue was that the same patient may have been or was going to be in multiple facilities within the new enterprise. However, at each of the present facilities (physician office, medical center, and nursing home), the same patient would have different health record numbers. A plan for an enterprise health record number was needed. The medical center administration decided to bring in the health information management director of the medical center to provide expertise and experience in resolving the problem.
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