Page numbers followed by f refer to figures; page numbers followed by t refer to tables.
A
Accreditation Council for Graduate Medical Education (ACGME), 116, 128
Active practitioners in the U.S., 71, 74t
Activities of daily living (ADL), 145, 146t
Adequate access to care, 116
Adequate scientific knowledge, 116t
Agency for Health Care Policy and Research/Agency for Health Care Research and Quality (AHRQ), 122, 123
Ambulatory care physicians, 171, 172
American Association for Labor Legislation (AALL), 188
American Medical Association (AMA), 74, 188
Antismoking campaigns, 139–140
Autonomy, 153–154
nonmaleficence, comparison with, 155
B
Balanced Budget Act of 1997, 205
Beneficence, 160
Beveridge, William, 176
Blue Cross subscribers, 203
Blue Cross, 202–203
Blue Shield, 202
Breast cancer mortality rates, 142–143
Breast Cancer, 142–143
multiple risk factors, 142
British Medical Association (BMA), 177
British National Health Service (NHS), 44–46, 175–176
reforms of, 179–180
British system
of capitation payments, 35
of health care, 44–46
C
California Medical Injury Compensation Reform Act, 129
Canada’s universal insurance program, 174
Canadian family physicians, 174
Canadian health care system, 173
Canadian Hospital Insurance Act, 172
Carve-outs, 34
CHD. See Coronary heart disease Chief organized purchaser, disinterest of, 202
Chronic disease prevention, 137
medical model, 138
Clinical practice guidelines, 122–123
Clinton, Bill (U.S. President), health insurance plan of, 188
Commercial insurers, 202
Commodity scarcity through transplantation of organs, 158–59
Community health centers, 61–62
Community rating, 9. See also Experience rating
Community-based long-term care, 149
Competent health care providers, 116–117
Competitive strategies
for cost control, 104–106
Computerized information systems, 125
Computerized physician order entry (CPOE), 125
Concerted action, 172
Continuous quality improvement (CQI), 121, 125
Coronary artery bypass graft (CABG) surgery, 119–120
Coronary heart disease (CHD), 137, 139–143
age-adjusted mortality rates, 137–138, 141
due to cigarette smoking, 139–40
due to hypertension, 141–142
due to rich diet, 140–141
Continuous quality improvement (CQI) model, 121
systematically monitoring of health care providers, 122, 122t
CQI. See Continuous quality improvement
Curing Health Care, 118
Custodial services, 147
D
Department of Health and Human Services (U.S.), 158–159
Diagnosis-related group (DRG) method of payment, 39–40
Dispersed Model, 46–47, 59, 68, 69. See also
Regionalized Model Distributive justice, 154–155
DRG. See Diagnosis-related group
E
Earmarked health tax, 173
Employer mandate approach, 191, 198
Employer mandate plans, 191
criticism of, 198
Employment-based private insurance, 7–10
Employment-based social insurance model, 182
Employment-based privately administered national health insurance proposal, 191
End-of-life costs
of patients in hospice programs, 161
Enterprise liability, 130
Ethical dilemmas, 155–157
Experience rating, 9. See also Community rating
Experience-rated insurance, 148, 151
Explicit rationing, 158
F
Federal social insurance trust fund, 188–89
Fee-for-service payment, 31
Fee-for-service reimbursement, 32, 110, 117, 178
Financially Neutral Clinical Decision Making, 128
Financing controls
for health care, 103–106
weaknesses, 106
Financing medical education, 76
First epidemic revolution, 136
Fiscal reality, 156
Fiscal scarcity
resource allocation, correlation with, 158–159
Frontier Nursing Service, 61
G
Gatekeeping
in primary care, 51
German Cost Containment Act of 1977, 172
German national health insurance system, 170f
Good quality care, 120
Government financed insurance, 10–16, 14f
Government-financed national health insurance plans, 188–190
public assistance (welfare) model, 189
GPs and specialists
British, pay for performance (P4P), 177–178
Canadian, fee-for-service basis, 174
German, detailed fee schedule, 172
Japanese, per diem hospital payment based on diagnosis, 183
Griffiths, Martha, Michigan Representative, 190
Guaranteed medical benefits, 164
H
Harvard Medical Practice study, 116
Health care “report cards,” 125
Health care financing ethics, 165–166
Health care financing system, 197–198
Health care financing, 188
Health care institutions, 118
Health care market, consolidation in, 207
Health care outcomes
organization of health care systems and institutions, 119
Health care providers
socially useful cost savings, 159–160
Health care quality, crossnational comparisons, 183
Health care resources, 166–167
Health care sector
of U.S. economy, 201
in the U.S.
performance analysis, 97
organization of, 44–53
public’s view of, 2
quality of care, correlation with, 118–120
traditional quality assurance, 121–122
weaknesses, understanding of, 2–3
Health care
administrative overheads of, 98–99
balance in levels of, 47–48, 49t
cost control
in Canada, 175
categories, 104t
in Germany, 172
in Japan, 181
requirement of, 97
requirements for, 94
strategies, 97–101
in United Kingdom, 178
prioritization and analysis of, 100–101
cost saving
through disease prevention, 99
through innovation, 99
cost sharing, 108–109
costs, description of, 97
excess care, 2
patients with, 1–2
financial incentives, 53–55
financing of
modes, 14–15
generalism, role of, 53–54
historical overview, 206t
ineffective, elimination of, 97–98
inflation, 91
control of, 97
need and cost of, 5–6
gender and race factors, 25–26
payment modes, 5–15
physician recommendations, implications of, 6–7
relation with health status, 26–28
socioeconomic status, influence of, 27–29
resource input and outcomes, correlation in, 94–97
traditional structure of, 59–60
Health care, tensions, 206t
Health insurance premiums, 166
Health insurance
in Canada, 172–73
tax-financed, public, single-payer health care system, 172
essence of, 20
in Germany, 169–171
merged social insurance and public assistance structure, 171
health care services, implications of, 21
in Japan, 180–82
factors for, 18–19
limitations of, 23
nonfinancial barriers, 24–26
in United Kingdom, 175–76
Health Maintenance Organization Act, 65
Health maintenance organizations (HMO), 32, 73
contracting of, 204–205
decline of, 205
Independent practice associations (IPA) model, 65–67
prepaid group practice, basis on, 62–63
second generation, 65–67
Health maintenance, 63
Health plan employer data and information set (HEDIS), 126
Health policy
abstract concepts in, 215–216
goal of, 213
concerns of, 91
Health reform law, Massachusetts, 193
Health workers
supply of, 81–83
underrepresented minorities, representation of, 86–87, 87f
Health Commissioner projects, Limittown, U.S.A., 160
Heritage plan, 191
High blood pressure, primary prevention, 142
High-deductible health plan (HDHP), 193
High-dose chemotherapy with autologous bone marrow transplantation (HDC-ABMT), 162
High-quality health care, 115–120
HMO. See Health maintenance organization Home care agencies, 149
Home health services medicaid coverage of, 147
Hospital payment methods, 39–40
Hospital Quality Initiative, 126
HSA. See Health savings account Hybrid national health insurance proposals, 190
in California, 190
I
Ideal long-term caregivers, 151
Illegal drug use, 166
Independent practice associations (IPAs), 65
Indiana Medical Malpractice Act, 129
Individual health care consumers, 201
Individual mandate health insurance, 192–193
Individual mandates, 193–194
Individual patients, maximizing care, 163
Individual physician report cards, 126
Individual private insurance, 7, 7f, 14
Infant mortality
race, correlation with, 28–29, 28t
Infectious disease mortality rates, 136
Informal caregivers, 148
In-hospital medical errors, 125
Institute for Healthcare Improvement (IHI), 125
Instrumental activities of daily living (IADLs), 145
Insurance co-payments, 24
Insurance deductibles, 24
Insurers and providers of care, alliance of, 202
Insurers, 197
Integrated organizations, 69
Integrated Healthcare Association (IHA) program, 127
Investor-owned “for-profit” status, 207
IPA. See Independent practice associations
J
Japan’s community-based health insurance/citizens’ health insurance, 181
Joint Commission on Accreditation of Hospitals/Joint Commission, 121
Journal of the American Medical Association, 60–61
Justice, 154
K
Kaiser–Permanente medical care program, 63–65
Kennedy, Edward, Massachusetts Senator, 190
Kennedy-Griffiths Health Security Act of 1970, 190
Knifeless’ gamma ray surgery, 43
L
LCME. See Licensing Council on Medical Education Licensing agencies, 121
Licensing Council on Medical Education (LCME), 74
Life-expectancy
race, correlation with, 27, 27t
Long-term care policies, 148
Long-term care, 139
activities requiring assistance, 146t
deinstitutionalizing, 151
direct out-of-pocket payments, 146
financing of, 150–151
out-of-pocket expenses, 146, 196
Lower-income people, nursing home care, 150, 193
M
Malpractice liability system, 128
negative side effects on medical practice, 128–129
Managed care plans, 13, 32, 66, 112
Maximizing care for each patient, physicians’ single-mindedness, 166–167
Medicaid long-term coverage, 147–148
Medicaid public assistance model, 13
Medicaid, 10, 11t–12t, 13, 23, 189
health care access through, 23
Medicaid/SCHIP (beneficiaries), 2007, 10, 12t
Medical care
in Canada, 173–74
costs of, influence of prevention, 143
financial considerations and quality, 117
in Germany, 171
in Japan, 182
in United Kingdom, 175–76
Medical commons, 166
Medical education, 74–75
Medical ethics, 153
principles of, 153–154
Medical injury, alternatives to jury trials, 129
Medical insurance. See Health insurance Medical negligence, 115, 117–120
Medical reimbursements, 31
Medicare Advantage program, 10, 11, 70
Medicare coverage disparities, 23t, 24
Medicare long-term coverage, 147
Medicare Modernization Act of 2003, 10
Medicare Part D, 10–11, 24, 109
Medicare Prospective Payment System (diagnosis related groups [DRGs]) of 1983, 204
Medicare’s budget, 161
Medicine, commercialization of, 118
Methods of payment, 31–32
Microallocation, 164
daily clinical decisions, 167
Mortality rates
in the U.S., 115
Multidisciplinary group practice, 215
Multispecialty group practice, 60–61
Multispecialty groups, 209
N
National Cholesterol Education Program, 140
National Committee for Quality Assurance (NCQA), 115, 126
National health expenditures per capita, 91, 92f, 108
National Health Insurance (U.S.), 195–199
benefit package, 195
cost containment, 196–197
patient cost sharing, 195–196
National Organ Transplantation Act of 1984, 159
NHS. See British National Health Service NIH cholesterol reduction strategy, 141
Nixon, U.S. President, 190–191
No-fault malpractice reform, 130
Nurse practitioners, 78–80
Nurses
demand and need, 80–81
Nursing homes, 149–150
O
Omnibus Budget Reconciliation Act of 1987, 150
Open and closed medical care systems, role of ethical considerations, 166
Oregon Health Plan, 163–64
Organ allocation, 159
Organizing care, models of, 44
Outcome measures, 123
Outcomes, 123
Out-of-pocket payments, 5, 7, 15, 146, 196f
Overuse–underuse spectrum, 118
P
Panel management
in primary care, 51–52
Patient-centered medical home, 51–52
Patients’ persistent financial barriers, 215
Pay for Performance (P4P), 127–128
Pay for Reporting, 126–127
Paying physicians and hospitals
in Canada, 174–175
in Germany, 171
in Japan, 182
in United Kingdom, 177
Payments
for all services, 32
per episode of illness, 31, 33–34
per hospitalization episode, 39–40
per institution, 40
per patient
to hospital, 40
per procedure
for hospital, 40
for physician, 32–33
per time, 38
PCP. See Primary care physician
Peer review, 121–122
theory of bad apples, 121
Pepper Commission of 1990, 151
Pharmaceutical industry (U.S.), 209–210
Pharmacists, 80
shortage of, 84
Pharmacy technician, 84
Physician assistant education, 77–78
Physician assistants (PAs), 76–77
Physician entrepreneurship in Japan, 182
Physician organizations, funding of, 127
Physician payment methods, 32–33
Physician practices, 177
Physician Quality Reporting Initiative, 120, 126
Physician–industry relationships, 210
Physicians for National Health Program, 151, 190
Physicians, 73–74
financial incentives, 53–55
in traditional fee-for-service, 59–60
professionalism, 55–56
supply of
relation with mortality, 84
Postdoctoral education, 75–76
PPO. See Preferred Provider Organization Practice organizations, patterns of care, 120
Preferred Provider Organization (PPO), 32–33, 68–69
Prepaid group practice, 62–63
Prescription drug, efficacy and clinical trials of, 210–211
Prevention, strategies, 135–136
Price controls, 8, 101, 104t, 106, 107
Price, 96–97
Primary care physician (PCP), 35, 46, 50, 171
Primary care physician, 171
Primary care trusts, 179
Primary prevention, 135
through public health action, 143
Private insurance, 148
Private insurers, 171
Private long-term care insurance, 148
Process measures, 123
Process of care, 123
Profitability, 209–210
Profoundly ill people, medical care, 160
Promotion of good health and the prevention of illness, 135
Provider-insurer pact, 201–202, 205–206
Providers, 201
Providing or withholding of care, 162
Purchaser dominance over health care, 205
Purchasers, 201
revolt, 204–205
Q
Quality improvement organizations (QIOs), 121
Quality monitoring, contemporary approach, 124
Quality of care, 119
proposals for improvement, 120–121
public reporting of, 125–126
Quantity, 97
R
Rand Health Insurance Experiment, 24, 109
Rationing
by medical effectiveness, 162
for society as a whole, 162
relationship to cost control, 160
within one institution, 164
Regionalized Model, 44, 45f. See also Dispersed Model Registered nurse education, 78
Registered nurses, 77–78, 80, 82
Regulatory strategies for cost control, 103
Reimbursement controls for health care, 104, 106–107
Risk adjusted capitation, 34, 115, 126
S
San Francisco, On Lok program, 151
San Joaquin Foundation for Medical Care, 65–66
SCHIP. See State Children’s Health Insurance Program
Second epidemic revolution, 136
Secondary care, 44
Secondary prevention, 135
Selective contracting, 205
Self-insurance placed employers, 204
Sickness funds, 169–171
Single-payer detractors, 198
Single-payer proposals, 196–197
Single-specialty groups, 208
Skilled care versus custodial services, 147
Smoking cessation, physician counseling, 143
Social insurance model, 13–14, 189
Social insurance, 151
Social–ethical dilemma, 155–156
Society-managed insurance plans, 180
Specialist physicians and specialty services, financial incentives, 208
Specialty service lines, 209
Sponsored collaboratives, 125
Starfield, Barbara
primary care tasks, formulation of, 49
State Children’s Health Insurance Program (SCHIP), 13, 19, 69, 181, 187, 190, 196
Statin drugs, treatment for hyperlipidemia, 123
Suppliers, 201
control of, 111–112
T
Task Force on Organ Transplantation (1986), 159
Tax credits, 191–192
Tertiary care, 43–44, 47, 214, 218–219
Three-tiered capitation, 35–36, 37f. See also Two tiered capitation
Tobacco, 139
Tort reform, 129
Traditional insurers, 201
Truman, Harry S., U.S. President, 189, 193
Two-tiered capitation, 35–36. See also Three-tiered capitation
U.S. health care system
1945–1970, 198
1970s, 203
1980s: purchasers’ revolt, 204–205
1990s: provider–insurer pact, breakup of, 205–206
managed care, 206
new millennium: re-emergence of provider power, 206–207
unstable power relationships, 210
effects of, 24
Unemployment benefits, 154
Uninsured people, 17, 18f, 20, 21f
health outcomes, 22–23
Unit of payment, 31, 107–108, 112
UM, relation with, 106
United Network for Organ Sharing (UNOS), 159
United States system
of capitation payments, 34–36
of health care, 46
Units of payment, 31–32
Universal health insurance through an employer mandate, 187, 189, 191
Universal individual insurance proposals, 195, 197
Utilization (quantity) controls, 100–112
Utilization management (UM)
in health care, 109
V
Vertical integration, 64, 64f, 67
Voluntary approach, 191
W
Wagner–Murray–Dingell Bill, 188–189
Welfare benefits, 155
World War II, rationing, 160
Worthy, Joshua, 91