1. Chapter 3 The U.S. Health and Public Health Care Systems
Bonnie Jerome-D’Emilia
Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

2. Introduction
This chapter describes a health care system in transition as it struggles to meet evolving global and domestic challenges
Nurses play a pivotal role in meeting these needs
Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

3. Forces Stimulating Change in the U.S. Health Care System
Demographic trends
Social and economic trends
Health workforce trends
Technological trends
Demographic Trends: Increased fertility and Decreased mortality; “Baby Boom” and “Baby Bust”; Increasing average age; Change in largest minority group (African-American to Hispanic); Change in household composition (more single-parent homes); Leading deaths changed from infectious diseases to chronic and degenerative diseases
Social and Economic Trends: Changing lifestyles (to be healthy one must take care of one’s self); Growing appreciation of the quality of life (shift in values changing the importance of financial success); Changing composition of families and living patterns; Rising household incomes; Gap between the richest and the poorest is widening; Revised definition of quality health care
Health Workforce Trends: Not enough primary care providers, especially in the most underserved areas (i.e., inner cites, very rural areas); Move to contain costs and move to community-based care; Current nursing shortage; Need to increase number of minority nurses to help decrease health disparities
Technological Trends:
Positive effects:
Improve health care services
Reduce costs (efficient means of delivering care; replacing people with machines)
More convenience (time and travel)
Negative effects:
Can also increase costs
High-tech. equipment is expensive, quickly becomes out-dated, often requires highly trained personnel
Legal liability
Potential for decreased privacy
Too much reliance on machines
Generation Y very comfortable with technology and expect healthcare providers to be as well
Technological disparity, “digital divide”
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4. Demographic Trends Population growth of the world
Impact of baby boomer generation
Hispanic persons now outnumber African-Americans as the largest minority group
By 2050, whites are predicted to make up only 50.1% of the U.S. population
U.S. household composition changing
Mortality for both genders in all age-groups has declined
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5. Social and Economic Trends
Changing lifestyles
Growing appreciation of the quality of life
Changing composition of families and living patterns
Changing household incomes
Average per-person income is increasing
Gap between the richest 25% and the poorest 25% is widening
Revised definition of quality health care
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6. Health Workforce Trends
Nursing shortage
By 2016, expecting 587,000 new nursing positions
55% of surveyed nurses intend to retire between 2011 and 2020
Need to increase number of minority nurses
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7. Technological Trends
Development and refinement of new technologies has opened up new clinical opportunities in the areas of managing chronic conditions and assisting persons who live in rural areas, as well as in home health care, rehabilitation, and long-term care
Technological advances promise improved health care services, reduced costs, and more convenience in terms of time and travel for consumers
“Digital divide”
Electronic medical records
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8. Current U.S. Health Care System
Cost
Per-person expenditures tend to increase each year; some people must choose between buying food or getting health care
Access
Two-class system: private and public
Rising number of uninsured persons
More than 47 million uninsured Americans; many more lack access to adequate care; largely due to loss of coverage by employment-based health plans
Two-class system:
Private = Those with insurance or who can pay for health care are viewed as receiving superior care
Public = Those who depend on public funds
Uninsured = working poor who do not qualify for public funds (either make too much money or are illegal immigrants)
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9. Current U.S. Health Care System (cont’d)
Quality
Institute of Medicine (IOM) report – To Err Is Human: Building a Safer Health System (2000)
Revealed that as many as 98,000 deaths a year were attributed to preventable medical errors
The IOM recommended financial and regulatory incentives to lead to a safer health care system
Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

10. Organization of Health Care System
An enormous variety of facilities and providers make up the health care system
In general, American health care system is divided into two components
Private or personal care
Primary care system
Community health center
Public health
Public health system
A variety of facilities and providers make up the health care system
Example: Physicians’ and dentists’ offices, hospitals, managed care organizations, nursing homes, mental health centers, rehabilitation centers, and local, state, and federal official and voluntary agencies
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11. Primary Care Versus Primary Health Care
Primary health care (PHC) is more broad than primary care
The setting for PHC is within all communities of a country and involves all aspects of society (World Health Organization, 1978)
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12. Primary Health Care (PHC) Defined
Includes comprehensive range of services, including public health; prevention; diagnostic, therapeutic, and rehabilitative services
PHC is essential care made universally accessible to individuals and families in a community
PHC encourages self-care and self-management in health and the social welfare of daily life
A PHC strategy seeks to ensure individual, family, and community self-reliance and competence
Declaration of Alma Alta
Healthy People 2010 goals:
Increasing the quality and years of healthy life
Eliminating health disparities among racial and ethnic groups
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13. Primary Care Defined
Refers to personal health care that provides first contact and continuous, comprehensive, and coordinated care
Deals with the most common needs of community members by providing preventive, curative, and rehabilitative services
Managed care (HMOs and PPOs) use primary care as the starting point to access to care
Advanced practice nurses, such as nurse practitioners, clinical nurse specialists, and certified nurse-midwives, are vital to the primary health care workforce team
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14. Public Health System
Seeks to ensure that the health of the community is protected, promoted, and ensured
Overlaps with the primary care system
Mandated through laws developed at the national, state, or local level
Organized into multiple levels, including the federal, state, and local systems
At the local level, health departments provide care that is mandated by state and federal regulations
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15. Federal Systems Department of Health and Human Services
National Health Service Corps
U.S. Public Health Service
Health Resources and Services Administration (HRSA)
Bureau of Health Professionals
National Institutes of Health (NIH)
Agency for Healthcare Research and Quality (AHCRQ)
Food and Drug Administration (FDA)
Centers for Disease Control and Prevention (CDC)
Centers for Medicare and Medicaid Services (CMS)
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16. Federal Systems (cont’d)
Department of Homeland Security (DHS)
Department of Agriculture
Department of Justice
Department of Commerce
Department of Defense
Department of Labor
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17. State and Local Systems
State systems
State boards of nursing
State health departments
Local systems
Local health departments
Services and programs offered by local health departments vary depending on the state and local health codes that must be followed, the needs of the community, and available funding and other resources
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18. Forces Influencing the Health Care System of the Future
Consumers
Employers (purchasers)
Managed care systems and other major health care systems
State and federal legislation
Consumers want lower costs and high-quality health care without limits and with improved ability to choose providers of their choice.
Employers want to be able to obtain reasonably priced basic health care plans for their employees.
Managed care organizations and other major health care systems want a better balance between consumer and purchaser demands.
Legislation concerning access and quality continues to be enacted.
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19. Transformation of the Health Care System: What Does the Future Hold?
Research will continue to investigate the problems of the current health care system
Evidence-based practice
Solving the health care crisis requires the institution of a more logical health care system, a system that balances equity, cost, and quality
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20. What Is Needed to Improve Health Care?
In the U.S., the health care pyramid has always seemed to be upside down – that is, the majority of funds are spent on high-cost reparative care
A more logical system would build upon a base of public health, followed by primary care, and then by specialty care
Integration of primary care and public health is needed for the future health of the nation
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21. Community-Oriented Primary Care (COPC) Model
A community-responsive model of health care delivery that integrates both primary care and public health by combining the care of individuals and families with a focus on the community
Seeks to improve the health care system by building upon a base of public health instead of upon a base of tertiary care, as is current practice
Nurses are well suited for a COPC model because of their skills in assessment, health promotion, and disease prevention; knowledge of community resources; and ability to develop relationships with community members and leaders
Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.