1. HCA 701: Survey of the U.S. Healthcare System Physicians and Ambulatory Care

2. RESOURCES NEEDED TO MAINTAIN A HEALTH CARE DELIVERY SYSTEM Financing Healthcare Professionals Technology & Supplies Health Care Delivery System Facilities Source: Williams and Torrens, Introduction to Health Services, 2002

3. Healthcare Professionals Healthcare is a major employer It has a rapidly growing labor sector Professionals Non-professionals and technicians Non-institutional workers Rapid growth due to: Technology growth and specialization Health insurance coverage Aging population Emergence of hospitals

4. Types of Healthcare Worker Certification Licensure – state or legal designation Certification and registration Independent and dependent professions Independents practice without physician supervision (e.g., doctors, dentists) Dependents need physician supervision (most nurses, CNAs)

5. Ambulatory Care Personal health care given to the patient in an non-hospital or institutional setting Types of settings: Physician owned private practice Managed care clinic settings Community health care settings “Urgent care” facilities Shift to ambulatory care due to several factors: Medicare PPS Managed care Improved technology

6. Patient Visits per 100 persons by Ambulatory Service Type, 1993-94 and 1999-2000

7. Physician Authority Based on modern science and scientific knowledge. Physicians become the intermediaries between science and private experience Authority signifies the presence of status and quality Requires legitimacy and dependence. Legitimacy – acceptance by subordinates Dependence – bad things can happen if we don’t obey Types of Physician Authority Social Authority Cultural Authority Professional Authority

8. The Evolution of the Physician in the U.S. Allopathic Homeopathy Osteopathic Chiropractic

10. Physicians Comprised of two types by practice Primary care physicians – short supply in U.S. Family Practice, Internal medicine, OB/GYN, Pediatricians Specialists – Surplus in U.S. Specialize in specific areas

11. Physician Surplus or Shortage? Rapid growth of physicians, esp. specialists, during 1980-95 due to: Massive federal outlays Influx of International Medical Graduates (IMGs) Distribution of physicians gives appearance of shortage Not enough primary care providers Medical underserved areas in rural communities and inner cities Malpractice and the impact on physicians

12. Physicians: NV vs. US Physicians TypeNevadaU.S. Physician generalists per 100,000 population 2130 Physician specialists per 100,000 142206

13. Changing Role of the Physician More employed physicians By managed care organizations and hospitals (the emergence of the “Hospitalist”) Large group practices emerged with the growth of managed care Emphasis away from specialty areas to managed care More female physicians

14. Physicians who would recommend the practice of medicine

15. For physicians who wouldn’t recommend medical profession

16. Distribution of Physicians by Specialty: 1980, 1986, 1995, 2000 (In thousands 1980 1986 1995 2000 Pct. Change SpecialtyNo./% No./% No./% No./%1986-2000 All specialties414/100 521/100 630/100 684/10031.4 Primary Care159/38.5 179/34.4 205/32.5 219/32.022.2 Other Medical Specialties 25/6.2 62/12.0 83/13.2 94/13.7 50.2 Surgical Specialties110/26.7 134/25.7 158/25.2 170/24.927.0 All other specialties118/28.5 144/27.8 183/29.1 201/29.438.9

17. Physician Medical Education Undergraduate medical curriculum Most emphasize the acute care setting Increase in women and minorities Graduate medical education Major increases in residencies Shifts in the organization of medical schools Must compete for patients Shift to managed care by med school hospitals Trends medical education in for-profit hospitals Flexnor Report

18. Will doctors meet demand in a bio- terror event

19. Nurses Typifies the concern of healthcare: “nursing is concerned with human response to health problems” Historic factors that shaped nursing as a career: Occupation to support physicians Emergence of hospitals as community institutions Acceptable female occupations, primarily white females Linked to religious orders

20. Understanding the Nursing Shortage Changes in occupational opportunities for women since 1970s Majority of RNs are 50+ years of age or married with children at home Low salaries – pay compression Burnout Lack of clinical career ladder Active vs. Inactive – about 1/3 of nurses not working fulltime