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Introduction to the
U.S. Health Care System
Dr. Joe Saviak
Shi and Singh, Delivering Health Care in America: A Systems
Approach (2008, 2012)
Jonas, Goldsteen, & Goldsteen, An Introduction to the U.S.
Health Care System, 6th Edition, (2007)
Visuals by Google Images
Introduction
Course Objectives
 To develop subject matter competency through a study of the U.S. health care
system – health care impacts you each day as patients, parents, caregivers,
taxpayers, employees, managers, and employers. Whether you work in law
enforcement, social services, the fire service, education or local government, you
cannot avoid health care issues involving you, your workforce, or the citizens you
serve.
 To strengthen your problem-solving skills – Students graduating from the Public
Administration Program must have the ability to design evidence-based solutions to
effectively address administrative challenges in their agency and real world problems
within their community. During your careers, you will be asked to help develop plans
to solve or make measurable progress on community challenges or public needs your plans will always have to contain several key elements: problem/need, service
population, financing, means of delivery, timetable, evaluation, etc.. In this course,
your team will research, develop, and present a proposal to effectively address a
major challenge within the U.S. health care system.
 To enhance your skills in conducting and evaluating a public policy debate.
Chapter 1
A Distinctive System of
Health Care Delivery
Chapter 1
What is a health care system?

The sum of all institutions and processes that support the work of diagnosis &
healing (Jonas, Goldsteen, & Goldsteen, 2007)

Major components of the system and processes that enable people to receive
health care (Shi & Singh, 2008)
Primary Objectives of a Health Care System (Shi & Singh, 2008)
1. To enable all citizens to receive healthcare services whenever needed – universal
access.
2. To deliver services that are cost-effective and meet certain pre-established
standards of quality.
Health: a state of complete physical, mental, & social well being and not merely the
absence of disease or infirmity (World Health Organization,1948)
Chapter 1
Overview of Size & Scope of the System

Total employment in U.S. health care is approximately 10 million

744,00 active physicians

2.2 million active nurses

168,000 dentists

226,000 pharmacists

More than 700,000 health care administrators

5,760 hospitals

16,100 nursing homes

174.5 million Americans with private health insurance

41.7 million Medicare beneficiaries

42.5 million Medicaid recipients

1,300 health insurance companies

300 medical, dental, & pharmacy schools
Chapter 1
Who are the major players in the U.S. health services system?

Key players in the system include physicians, administrators of health service institutions,
insurance executives, large employers, and the government.
What main roles does the government play in the U.S. health services system?
1. The government is a major financier of healthcare delivery through the Medicare and
Medicaid programs – more than 45% of the $ in the system is public $ - 4 roles in financing health
care:
1) fund its own health care providers (i.e. VA Hospital)
2) fund health services thru grants to state & local govts.
3) fund medical education & research conducted by private & non-profit entities
4) fund government insurance programs which pay providers to deliver health care services
(Medicaid, Medicare, SCHIP) - the government determines eligibility criteria as to who can receive
services under these programs; it also determines the reimbursement rates that providers will receive
for rendering services to Medicaid and Medicare patients.
2. The government also regulates the healthcare industry through licensing of personnel,
healthcare establishments and health care products - licensing of physicians to certificates of
need for new hospitals to approval of new pharmaceutical drugs – regulation also includes
environmental health.
3. The government also designs and implements health policy – provides the
policy/legal/regulatory framework for the financing & delivery of health care affecting cost, access,
& quality.
Chapter 1
What main roles does the government play in the U.S. health services system?
4. Govt. may also be more than the payer but also serve as the provider directly
delivering health care services to specific patient populations such as veterans,
Native Americans, & the indigent – when govt. is the direct provider of personal
health services, it largely breaks out along these lines:
 At fed. level, it is population-specific - provided to specific categories of persons
such as veterans & Native Americans
 At state level, it is disease-specific - mentally ill, TB
 At local level, it is largely class-centered - indigent care
5. Govt. also funds & directs much medical research (i.e. NIH, CDC)
6. Responsible for public health priorities and programs - Emerson’s “Basic Six”
services of public health at state & local level: vital statistics, public health labs,
communicable disease control, environmental health, maternal & child health, and
public health education – consensus with private health care sector that these
services are appropriate for state & local govt. involvement/delivery
Chapter 1
Initial Analysis of the U.S. Health Care System – Identifying Strengths &
Limitations

The U.S. leads the world in medical technology, medical training, & research –
offers some of the most advanced institutions, products, & processes in the delivery
of health care

Pretty high degree of physician autonomy (even with rise of managed care) - most
medical decisions in U.S. are physician-driven – physician has discretion to order
tests, admit to hospital, refer to specialist, & generally influence course of treatment &
use of resources – “System costs and efficiency flow from the physician’s pen.”
(physician orders all tests, appointment, treatments, & referrals to specialists – in this
way physician autonomy operates as a key driver of system costs)

Functionally fragmented – lack of coordination among institutions & actors within
the system – “not a system in the true sense” (p. 2) – no central planning for
system-wide spending & functions as occurs in government run models in other
countries - American system is highly decentralized & fragmented - not a nationally
directed system like Britain – is this a problem?

Not a free market but not a government run system either (not a pure market model
and not a pure government model) – a hybrid of public and private involvement in
the financing and delivery of health care – 55% of the money in the system is
private – 45% is public money – highly regulated
Chapter 1
Initial Analysis of the U.S. Health Care System – Identifying Strengths &
Limitations

ERs are overwhelmed - In 1986, Congress enacted the Emergency Medical
Treatment & Labor Act (EMTALA) to ensure public access to emergency services
regardless of ability to pay. Section 1867 of the Social Security Act imposes specific
obligations on Medicare-participating hospitals that offer emergency services to
provide a medical screening examination (MSE) when a request is made for
examination or treatment for an emergency medical condition (EMC), including active
labor, regardless of an individual's ability to pay. Hospitals are then required to
provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize
a patient within its capability, or if the patient requests, an appropriate transfer should
be implemented (USDHHS, 2009). A significant segment of patients utilize ERs
as their primary care clinics – high cost of defensive medicine (i.e. $1,500
instead of $100), patients wait until they are in worse condition, ER not
designed to deliver primary care that is coordinated, comprehensive, or
continuous, no prevention, cost of transport to local taxpayers – patients with
emergencies have to wait in congested ERs, huge cost of uncompensated care
for hospitals who then have to cost shift to paying patients

EMTALA essentially means we currently have a system of universal access – critical
need to depopulate our ERs as this is helping to bankrupt American health care
Chapter 1
Initial Analysis of the U.S. Health Care System – Identifying Strengths &
Limitations

System has significant issues of duplication, waste, inefficiency, & complexity
– lack of coordination and planning at the macro-level - no one entity charged with
system-wide cost containment (“Everyone at the table is there to increase my
costs” – Dr. Klepper)

We spend a lot & have high tech but don’t achieve what we should in terms of
quality (IOM – Crossing the Quality Chasm)

Lack of focus on prevention

Issue of health disparities - significant differences in health status among
subpopulations

How do we best provide health care to the indigent and uninsured?

3 issues define the debate over the future of American health care: access, cost,
and quality
Chapter 1
THE QUAD-FUNCTION MODEL
All systems have these 4 functional components of healthcare financing and delivery –
depending on the type of system, these 4 functions are organized differently
1.
Financing - to purchase insurance or to pay for healthcare services consumed –
can be private through employer-based health insurance or privately purchased by
an individual – can be government financed through Medicare or Medicaid – most
private insurance is employer-based (how did we end up with employer-based
insurance and does it create any problems? Stay tuned!)
2.
Insurance - to protect against catastrophic risk, determines the package of
services that insured individuals can receive & specifies how & where health care
services will be received – processes claims & disburses funds to providers
3.
Delivery - to provide healthcare services – a provider is any entity that delivers
health care services and receives insurance payment directly for those services
4.
Payment - to reimburse providers for services delivered – reimbursement is the
determination of how much to pay for a certain service (not necessarily what it cost
but how much it will be reimbursed) - funds come from premium paid to insurance
company or from the government (Medicare, Medicaid) – insurance company pays
provider & there may be an employee co-pay amount
Chapter 1
ACCESS

The ability of an individual to obtain health care services when needed
Access influenced by:

Financing and insurance are the key predictors of access – “health insurance is
the primary means for ensuring access.” (p. 11)

Delivery and payment also influence access but more indirectly (i.e. too few
physicians willing to see Medicaid patients due to low reimbursement rates from the
government – this impairs access)
Access is determined by four factors:
1. Ability to pay (health insurance)
2. Availability of services (delivery) - for example, certain rural and remote areas lack
adequate services
3. Payment - for example, many providers do not accept patients covered under
Medicaid because of low reimbursement limits from the government (payment rules
influence access)
4. Enablement barriers - for example, lack of transportation; racial, cultural, and
language barriers
Chapter 1
FINANCING AND INSURANCE MECHANISMS
1. Employer-based health insurance – private
2. Privately purchased health insurance – people purchase their insurance
as individuals paying directly or they self insure paying out of pocket as
health needs arise
3. Government programs – public health insurance programs include:

Medicare - elderly and certain disabled people (age sets eligibility)

Medicaid – low income individuals (income sets eligibility) – this is a
federal/state partnership (55% federal paid/45% state paid in Florida - $16.2
billion of Florida’s budget in FY 09/10)

SCHIP - children from low-income families who are not eligible for Medicaid
– this is a federal/state partnership
Chapter 1
How did we end up with a system of employer-based health insurance?

It was not an intentionally designed system based on evidence, research,
best practices, successful pilot programs, and a deliberative legislative
process crafting sound public policy

It is more accurately an unplanned national policy related to the
imposition of wage controls and a change in tax law with far reaching
consequences (the law of unintended consequences in full operation)
Chapter 1
“We have become so accustomed to employer-provided medical care that we
regard it as part of the natural order. Yet it is thoroughly illogical.
Why single out medical care? Food is more essential to life than medical care. Why not
exempt the cost of food from taxes if provided by the employer? Why not return to the
much-reviled company store when workers were in effect paid in kind rather than in
cash? The revival of the company store for medicine has less to do with logic than
pure chance. It is a wonderful example of how one bad government policy leads
to another.
During World War II, the government financed much wartime spending by printing money
while, at the same time, imposing wage and price controls. The resulting
repressed inflation produced shortages of many goods and services, including labor.
Firms competing to acquire labor at government-controlled wages started to
offer medical care as a fringe benefit. That benefit proved particularly attractive to
workers and spread rapidly. Initially, employers did not report the value of the fringe
benefit to the Internal Revenue Service as part of their workers’ wages. It took some
time before the IRS realized what was going on. When it did, it issued regulations
requiring employers to include the value of medical care as part of reported
employees’ wages. By this time, workers had become accustomed to the tax
exemption of that particular fringe benefit and made a big fuss. Congress
responded by legislating that medical care provided by employers should be
tax-exempt.” (Dr. Milton Friedman, 2001)
Chapter 1
WHY DO WE HAVE THE UNINSURED?
 It’s important to remember that the % of uninsured in America has stayed
relatively stable due to widespread employer-based health insurance and
availability of government insurance programs – 15% is the highest figure widely
disseminated
 A key question for reform: if 85% of Americans are currently insured (private &
public) and 15% are uninsured, do we devise a solution for the 15% uninsured
or change the entire system for 100% of Americans?
 Among the uninsured, we need to analyze why people are uninsured as we may
need to develop targeted solutions which address the specific underlying
causes for different categories of the uninsured – this is not a monolithic group
(100% identical) and once we examine the uninsured, we see that even the 15%
figure among all Americans is probably overstated
Chapter 1
So Who Are the Uninsured?
1. Unemployed - this matters in a system largely defined by employer-based insurance
– this would also include those who are between jobs and recent college grads
who are now entering the workforce and looking for their first job
2. Although many do, employers are not required to offer health insurance
3. Although many accept it an employment benefit, employees are not required to
purchase health insurance
4. To participate in government programs, people must meet eligibility criteria BUT it is
estimated that a sizable share of the uninsured are eligible for some public
insurance program (Medicaid, Medicare) but have not enrolled
5. Some individuals do the cost benefit analysis and choose to self insure or not
carry coverage – they may be young & healthy & able to afford insurance but prefer
to spend their income on other priorities
6. There is also the issue of illegal aliens and if they should be counted as uninsured –
they may be working off the books so when they are injured or sick, they go to the ER
Chapter 1
Managed Care
The premise is that utilization drives costs so if we manage utilization, we will manage
costs – it is true that utilization drives costs
Get control of payment, price, and utilization – integrate all 4 functions of health care
through managed care (financing, insurance, payment, & delivery) to control
costs
What is managed care? A system of health care delivery that (1) seeks to achieve
efficiencies by integrating the basic functions of healthcare delivery, (2) employs
mechanisms to control utilization of medical services and 3) determines the price at
which the services are purchased and how much the providers get paid
Managed Care Organization (MCO) – umbrella term for all types of managed care
entities – In 2006, 93% of Americans not on Medicare enrolled in some type of MCO
Chapter 1
Managed Care
Why did managed care develop?
1) Emergence of belief in new financial formula for health care – reduced utilization =
reduced costs (shift profits from fee for service physician model to a managed care
model so physicians lose $ but MCOs make $)
2) Pre-approval for services could decrease utilization
3) MCOs felt they had more leverage due to oversupply of physicians competing
for business (they could impose more conditions on providers who were happy to get a
steady stream of business in a competitive environment) - historically, “hospitals had
doctors & doctors had patients” – now, the MCO has the patients and the
hospitals/physicians are the providers
Chapter 1
What are the tools of managed care?
 Employer contracts with a managed care organization (MCO) who then offers a
selected health plan to its employees – the health plan engages certain providers
from which the enrollees can choose to receive routine services – the MCO has
negotiated fee arrangements with the providers based on either capitation or
discounts – capitation is a payment mechanism in which all health care services are
included under one set fee per individual (a predetermined fixed payment per
member per month – PCPM) – discounts are the alternative mechanism to
capitation & occur when the MCO has negotiated discounts with providers lower than
their customary fees for services (in return, they are getting access to a guaranteed
pool of patients through the MCO)
 Generally, HMOs use capitation and PPOs use discounts
 Plans are based on an expected level of utilization so MCOs employ tools to
manage utilization such as pre-approval to see a specialist or receive a specific
treatment (if not, the risk will exceed the rate paid and premium will not cover claims)
 The idea behind both tools is cost predictability
Chapter 1

Common types of MCOs: 1) HMO 2) Preferred Provider Organization (PPO) –
network of pre-approved providers & enrollees may go “outside network” but have to
pay additional fee for doing so – a set and pre-approved network of providers helps
insurers track & contain costs and for providers, it guarantees a steady stream of
work 3) Exclusive Provider Organization (EPO) – beneficiary must choose a
physician on the insurer’s list 4) Independent Practice Organization (IPO) – group
of docs who deal with more than one insurer
HMO Characteristics:
1) package of health services delivered by pre-selected physicians & hospitals
under contract
2) HMO serves an enrolled & defined population
3) HMO members enroll voluntarily
4) HMO paid a fixed & periodic payment from the 3rd party payer to cover the
enrolled population
5) provider assumes the risk if level of capitated payment is exceeded by services
delivered to enrolled population (financial risk/loss then shifts from insurer to provider)
Chapter 1
Trends that impacted managed care:
1) physician & consumer dissatisfaction
2) MCOs had to relax controls to retain market share due to
dissatisfaction
3) MCOs changed significantly from the original 1990s model
Chapter 1
PRIMARY CHARACTERISTICS OF THE US HEALTHCARE SYSTEM – 10 defining characteristics
which differentiate the U.S. health care system from other countries
1. No central agency governs the system - global budgeting becomes impossible
2. Partial access – access is based on insurance coverage – a segment of the population (15%) is
uninsured
3. Health care is delivered under imperfect market conditions – as a consumer, you don’t know
price & performance like you do with the purchase of other goods & services - moral hazard and
supplier-induced demand
4. Third-party insurers and payers - insurance entities (commercial insurance companies or
managed care organizations) become an intermediary between the financing and delivery
functions - this intermediary role results in higher administrative costs.
5. Multiple payers make the system more complex and cumbersome.
6. Balancing of power among various players prevents any single entity from dominating the
system
7. Legal risks influence practice behavior - legal actions lead to the practice of defensive
medicine
8. Development of new technology creates an automatic demand for its use
9. New service settings have evolved along a continuum
10. Quality is no longer accepted as an unachievable goal in the delivery of health care
Chapter 1
#1 - No Central Agency
 “No central agency monitors total expenditures through global budgets and controls
the availability and utilization of services” (p. 11)
 A global budget is a tool of public policy where the national government sets a
nationwide cap for annual spending on all health care – there are consequences to
global budgets: 1) utilization has to be controlled 2) access to specialists and
more expensive treatments/technology will be restricted – in cross-national
comparisons over national levels of health care spending, nations which employ
global budgets will always spend less than the U.S. where no single central entity
such as the federal government annually caps all health care spending
 Even though we lack the degree of central planning found in other systems, it would
be wildly inaccurate to suggest that the federal government or state governments do
not exert any influence over spending and utilization in American health care – health
care is highly regulated – for example, for providers who want to be certified to
deliver services to Medicare, Medicaid, & SCHIP beneficiaries & receive
reimbursement, they must adhere to standards of participation
Chapter 1
#2 – Partial Access
 In theory, we are a partial access system based on an individual’s ability to pay
and in theory, single payer nations offer a universal access system based on
government financing and delivering of all health care
 In reality, ability to pay does not truly govern access in America due to public
insurance programs and ER access and in reality, universal access promised is
not truly universal access delivered due to rationing, delays, and denial of care
– we need to have a full appreciation for what access is in theory and in reality across
competing models
 How is access to health care in the U.S. obtained?
1) those who have employer-based health insurance
2) those covered under a government health program
3) those who can purchase insurance out of their own private funds
4) those who can pay for services out of pocket
5) those who go to the ER
Chapter 1
#3 – A Imperfect Market (that’s putting it mildly)
 Health care in the U.S. does not operate as a free market - consumers lack
information about price and quality/performance of providers – there is limited choice
and competition (often the result of government regulation and not market forces) –
prices are often not set by the market (i.e. prices set by MCOs or by the government
payer) – the consumer is often not the payer – it is not a traditional customerproducer market transaction – it is a 3rd party payer system - the consumer orders
the service, the provider delivers it, and someone else gets the bill
 It is financed via insurance but insurance is designed for major expenses associated
with an unlikely and unexpected event – health care is a routine need, it is likely and
predictable yet we utilize the insurance model to finance its delivery - “Employer
financing of medical care has caused the term insurance to acquire a rather
different meaning in medicine than in most other contexts. We generally rely on
insurance to protect us against events that are highly unlikely to occur but that involve
large losses if they do occur—major catastrophes, not minor, regularly recurring
expenses. We insure our houses against loss from fire, not against the cost of having
to cut the lawn. We insure our cars against liability to others or major damage, not
against having to pay for gasoline. Yet in medicine, it has become common to rely on
insurance to pay for regular medical examinations and often for prescriptions.”
(Friedman, 2001)
Chapter 1
#3 – A Imperfect Market (that’s putting it mildly)
 With insurance, patients are insulated from the effects of the full cost of their
decisions to utilize and consume health care services – “When it’s an open bar,
everyone orders top shelf brands” (Dr. Bebber) – health insurance and a third
party payer system contribute to the problem of moral hazard - people behave
differently when they are not paying out of pocket every time they use a service –
encourages utilization – costs go up
 Insurance is premium paid based upon risk (risk sets rate - higher risk = higher
premium & lower risk = lower premium) – when the govt. legislates that insurers
cannot know or calculate pre-existing conditions into setting premium, how can the
insurance model operate in the financing of health care? (disconnects risk from rate
– higher risk customers will pay less than they should & lower risk customers will pay
more than they should)
 Another symptom of an imperfect market is supplier-induced demand where those
“who have a financial interest in additional treatments also create artificial demand”
(p. 15) – rather than the market generating demand, the producer inflates demand
- physicians may prescribe more appointments, tests, or treatment than is clinically
necessary – this may be profit-seeking or defensive medicine (ER doc orders full
range of tests) – this may also be a function of low reimbursement rates for
Medicare and Medicaid (make up for it with volume) or it may be fraud in the system
which is another form of supplier-induced demand (see Medicaid/Medicare expenses
– Miami)
Chapter 1
#3 – A Imperfect Market (that’s putting it mildly)
“Two simple observations are key to explaining both the high level of spending on
medical care and the dissatisfaction with that spending. The first is that most
payments to physicians or hospitals or other caregivers for medical care are
made not by the patient but by a third party—an insurance company or
employer or governmental body. The second is that nobody spends somebody
else’s money as wisely or as frugally as he spends his own. No third party is
involved when we shop at a supermarket. We pay the supermarket clerk directly: the
same for gasoline for our car, clothes for our back, and so on down the line. Why, by
contrast, are most medical payments made by third parties?
The answer for the United States begins with the fact that medical care expenditures are
exempt from the income tax if, and only if, medical care is provided by the employer.
If an employee pays directly for medical care, the expenditure comes out of the
employee’s after-tax income. If the employer pays for the employee’s medical care,
the expenditure is treated as a tax-deductible expense for the employer and is not
included as part of the employee’s income subject to income tax. That strong
incentive explains why most consumers get their medical care through their
employers or their spouses’ or their parents’ employer. In the next place, the
enactment of Medicare and Medicaid in 1965 made the government a third-party
payer for persons and medical care covered by those measures.” (Dr. Friedman, p.
6, 2001).
Chapter 1
The US healthcare market is imperfect because it does not meet the criteria of a free market.
1.
The health plans acting as intermediaries for the patients typically function as buyers of
healthcare services. The patient (customer) is not actually making the purchase.
2.
Patients lack the information necessary to make prudent decisions. Patients generally do
not know all the diagnostic methods, intervention techniques, and drugs available to treat their
specific conditions. Information on price and quality is also extremely difficult to obtain – this
makes it difficult to comparison shop between competitors as we do with other
goods/services.
3.
Prices are often set by the health plans. They are not determined by the interaction of the
forces of supply and demand.
4.
The consolidation of buying power into the hands of private health plans is forcing providers to
form alliances and integrated delivery systems on the supply side, thus restricting
competition at the individual level (both buyers and producers are consolidating).
5.
Health insurance shields patients against the cost of health care. Health insurance does not
always serve the purpose of true insurance, which is to protect against catastrophic risks.
For basic and routine care, health insurance acts as prepayment for health services. There is a
moral hazard that once enrollees have purchased health insurance, they will utilize healthcare
services.
6.
The utilization of health care is generally determined by need rather than price-based demand.
Providers can often induce demand for their own financial benefit.
Chapter 1
#4 - Third-party insurers and payers
The patient is the first party, the provider is the second party, & the insurer/payer
is the third party in the relationship – structuring the relationship like this has real
consequences – the insurer lacks the incentive to be the patient’s advocate in terms
of quality – the patient is insulated from the true effects of cost and is unable to shop
among competing providers on the basis of cost and quality – the patient can usually
only complain to their employer who may be reluctant to switch plans – the provider is
responsible to both the patient and payer and their interests may conflict (patient
wants a specific treatment but payer wants to contain cost)
#5 - Multiple payers make the system more complex and cumbersome.
With different patients covered by different plans, providers have difficulty knowing which
services are covered by which plans, claims processors must be hired to handle
billing multiple plans & monitoring payment, payments can be denied to providers for
failure to follow all rules, denied claims generate rebilling, collection efforts can be
costly & time consuming, government programs have complex regulations governing
payment – the end result of third party payers and multiple payers is that the
U.S. spends more on administrative costs than other health care systems –
combined cost of billing, collection, bad debts, & maintaining medical records
Chapter 1
#6 - Balancing of power among various players prevents any single entity from
dominating the system
Different players have different interests resulting in conflict and consequences
for the overall system – physicians want to preserve income and autonomy,
insurers & MCOs want to maintain market share, hospital executives want to
maximize reimbursement from private & public insurers, employers want to minimize
health care costs, and the government wants to contain costs while also keeping or
expanding benefits to constituents
#7 - Legal risks influence practice behavior - legal actions lead to the practice of
defensive medicine
Costs increase as physicians order tests and follow-up visits and keep copious
documentation for non-medical reasons – fear of litigation
Chapter 1
#8 - Development of new technology creates an automatic demand for its use
Several factors converge which almost guarantee that the “latest and best” technology
will be demanded and utilized:
1) Patients are much more aware of medical technology compared to previous
generations - patients now basically “order” specific tests & treatments rather than
the physician first telling them it should be done – this is a new phenomenon
compared to earlier generations – direct marketing of medical products via TV &
other advertising to consumers who have insurance & so they make the diagnosis
and recommend the specific treatment to their physician & they want the newest &
best technology
2) Hospitals and physicians compete on the basis of having the latest technology
3) Concern over litigation may discourage providers & health plans from denying use of
technology
4) Sunk costs – we made the capital expenditure – now, we have to recoup our
investment through utilization
Chapter 1
#9 - New service settings have evolved along a continuum
 There was a time when much medical care was delivered in either the hospital or the
physician’s office – inpatient care meant the hospital and outpatient care meant your
physician’s office
 Today, health care is provided in a wide range of settings – see Table 1-2 on p.
18 – shows the different delivery settings depending on the type of health care
service
 Home health care, outpatient surgical centers, public health & community programs,
and preventive care achieved in the “setting” of personal lifestyles are just a few
examples
#10 - Quality is no longer accepted as an unachievable goal in the delivery of
health care
 Higher expectations for improved health outcomes at the individual and community
levels – greater focus on evidence-based medicine
 Public, private, and non-profit organizations now employing tools to incentivize
quality and disincentive errors (i.e. pay for performance, accreditation standards
such as JCAHO, public disclosure laws of error rates, performance measures,
licensing requirements, etc.) – foster a culture of continuous improvement in
American health care – we no longer accept “this is as good as it is going to get”
Chapter 1
Competing Models for Health Care Systems

In theory, universal access is provided by a healthcare delivery system that (1) is managed by the
government and (2) provides a defined set of healthcare services to all citizens.
Three models of national systems:
1. National Health Insurance (NHI) – a tax-supported national healthcare program in which services
are financed by the government but are rendered by private providers. 3 of the 4 functions directly
done by government – most provinces utilize global budgets (Canada).
2. National Health System (NHS) - tax-supported national healthcare program in which the
government finances and also controls the service infrastructure – government operates most
medical institutions - providers are either government employees or organized in a publicly
managed institution - government oversees all 4 functions – global budget (Great Britain).
3. Socialized Health Insurance (SHI) - health care is financed through government-mandated
contributions by employers and employees, health care is delivered by private providers, and
private non-profit insurance companies called sickness funds are responsible for collecting the
contributions & paying the hospitals and physicians – global budgets utilized – government in
control of the system (Germany, Israel, and Japan).
**Shi and Singh provide brief descriptions of specific characteristics of several national health care
systems in different countries on pp. 22-28.
A major focus of this course will be to examine, discuss, and debate how we should design,
implement, and evaluate a health care system for America - thinking of the 4 major
functions of a health care system (financing, insurance, delivery, payment), how should it
be organized – a government model, a market model, or a hybrid?
Chapter 1
Trends and Directions
Cost, access, and quality are the 3 dominant themes in American health care
Goal: improve quality while reducing costs
Let’s change the question to a patient entering a hospital to “What’s wrong?”
instead of “What’s your insurance?” (Friedman, 2001)
Changing the focus/shifting the emphasis from (Shi & Singh, 2008):
 Illness to wellness
 Acute care to primary care
 Inpatient care to outpatient care
 Individual health to community well-being
 Fragmented care to managed care
 Independent institutions to integrated systems
 Service duplication to a continuum of services
Chapter 1
Trends and Directions
E-medicine – electronic health records (EHRs)/personal medical records
(PMRs)/electronic information sharing networks have been proposed to improve
quality, reduce errors, & boost efficiency – most small private physician practices still
depend on paper records – the advent of e-medicine could facilitate better tracking of
population level health trends & further enable better identification of clinical
interventions which hold the most promise – reduce defensive medicine – permit a
patient to walk into any clinic or hospital with their full medical records – could
encourage patients to become more active in their health/disease management telehealth - physicians communicating via the Internet - syndromic surveillance
(monitor for epidemics) - many issues to overcome (trust, technology, system
security, cultural, leadership, privacy, etc.) - electronic information integration remains
a major challenge for U.S. health care
Other priority issues: increasing the supply of primary care physicians, improving health
literacy, reducing health disparities, and targeting specific & worsening health
challenges (i.e. diabetes)
Lastly, what will be the results of health reforms at the national level?
Chapter 1 – Key Terms – Learning the
Language of Health Care
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Access - Refers to the ability of an individual to receive healthcare services when needed. In this
context, need is primarily determined by the patient. It is secondarily determined by a referring
physician, especially for higher-level services.
Administrative costs - Incidental to the delivery of health services. These costs are not only
associated with the billing and collection of claims for services delivered, but also include
numerous other costs, such as time and effort incurred by employers for the selection of insurance
carriers, costs incurred by insurance and managed care organizations to market their products,
time and effort involved in the negotiation of rates, and resources used in the completion and
maintenance of medical records.
Capitation - A payment mechanism in which all healthcare services are included under one set
fee per covered individual. The fee is generally paid per month, hence it is also referred to as permember-per-month (PMPM). The fee covers all services an enrollee may need during the entire
year. A charge is the fee (or price) set by the provider. The charge is the amount the provider
generally bills for services delivered. The payer may reimburse the charges only partially, which
may necessitate balance billing to the patient.
Defensive medicine - Involves the delivery of services and maintenance of documentation
undertaken primarily to guard against the risk of malpractice lawsuits. These additional efforts do
not generally add to the quality of care.
Demand - The quantity of health care demanded by consumers based solely on the price of those
services. Enabling services, such as transportation or translation services, facilitate access when
an individual already has health insurance coverage.
Chapter 1 – Key Terms – Learning the
Language of Health Care
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An enrollee - An individual enrolled in a health plan and therefore entitled to receive health
services the plan provides.
A free market - Characterized by the unencumbered operation of the forces of supply and
demand when numerous buyers and sellers freely interact in a competitive market.
Global budgets - Used to control costs in centrally managed systems. System-wide healthcare
expenditures are budgeted. Resources are allocated within the budgetary limits. Availability of
services and payments to providers are subject to such budgetary constraints.
Health plan - Two basic meanings: (1) It can refer to any type of health insurance plan. (2) From
a macro-systemic perspective, a managed care organization (MCO) responsible for furnishing
services under a health plan is also referred to as the health plan, in contrast to an insurance
company or carrier for a traditional health insurance plan.
Inpatient care - Refers to a patient who is institutionalized (the state of being in an institution) or
to services provided in institutional settings that require an overnight stay.
Managed care - Seeks to “manage” the utilization of medical services, the price at which these
services are purchased, and consequently, how much the providers get paid. Managed care also
seeks to achieve better efficiencies in these areas by integrating the basic functions of healthcare
delivery.
Medicaid - The government insurance program for the indigent.
Medicare - The government insurance program for the elderly and certain disabled individuals.
Chapter 1 – Key Terms – Learning the
Language of Health Care
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Moral hazard - The term used to explain the increased utilization of healthcare services when people have health
insurance coverage.
National Health insurance (NHI) - A tax-supported health plan that ensures universal access. Services are
financed by the government but are rendered by private providers.
National Health System (NHS) - A tax-supported health plan that ensures universal access; but in this case, the
government also controls the service infrastructure.
Need for health services (in contrast to demand for health services) is based on individual judgment. The patient
makes the primary determination of the need for health care and, under most circumstances, initiates contact with
the system. The physician may make a professional judgment and determine need for referral to higher-level
services.
Outpatient care - Refers to a patient who receives services in an outpatient setting or to the services that are
delivered on an outpatient basis. Such services are also referred to as ambulatory services.
Premium cost sharing - Refers to the common practice by employers that require their employees to pay a
portion of the health insurance cost.
Primary care - Basic and routine care delivered by a general practitioner. In a managed care system, the primary
care physician also makes the determination for the need for higher-level services.
A provider - Can be an individual health care professional, a group, or an institution that delivers healthcare
services and receives reimbursement directly for those services. A registered nurse who is employed by a hospital
is not a provider since his or her services cannot be billed for reimbursement. The same registered nurse working
as a nurse practitioner in private practice could be a provider if he or she can bill for services.
The Quad-Function Model - Includes the key functions of financing, insurance, delivery, and payment.
Chapter 1 – Key Terms
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Reimbursement - The amount paid to a provider by the insurer. The payment may be only a
portion of the actual charge.
SCHIP - State Children’s Health Insurance Program. Joint federal/state program to provide
insurance coverage to children from low income families who are ineligible for Medicaid.
Single-payer system - Refers to a system in which there is a single payer as opposed to multiple
payers. The single payer is generally the government, as is the case in a national health insurance
program.
In a Socialized Health Insurance (SHI) system, such as in Germany, health care is financed
through government-mandated contributions by employers and employees. Health care is
delivered by private providers.
Standards of participation - Minimum quality standards established by government regulatory
agencies to certify providers for delivery of services to Medicare and Medicaid patients.
Supplier-induced demand - Refers to the demand for healthcare services created by providers
for their own financial benefit.
System - A network of interrelated components that have been designed to work together
coherently.
Third party - An intermediary between patients and providers. Third parties carry out the
functions of insurance and payment for healthcare delivery.
Uninsured - People who are without health insurance coverage.
Universal access - Means that all citizens have access to at least a basic package of healthcare
services.
Utilization - Refers to the quantity of health care consumed.
Critical Concepts – Chapter 1
What main roles does the government play in the U.S. health services system?
1. The government is a major financier of healthcare delivery through the Medicare and Medicaid programs –
45% of the $ in the system is public $ - 4 roles in financing health care:
1) directly fund its own health care providers (i.e. VA Hospital) 2) indirectly fund health services thru grants to state
& local govts. 3) indirectly fund medical education & research conducted by private & non-profit entities and 4)
fund government insurance programs which pay providers to deliver health care services (Medicaid, Medicare,
SCHIP) - the government determines eligibility criteria as to who can receive services under these programs; it
also determines the reimbursement rates that providers will receive for rendering services to Medicaid and
Medicare patients.
2. The government also regulates the healthcare industry through licensing of personnel, healthcare
establishments and health care products - licensing of physicians to certificates of need for new hospitals to
approval of new pharmaceutical drugs – regulation also includes environmental health.
3. The government also designs and implements health policy – provides the policy/legal/regulatory framework
for the financing & delivery of health care affecting cost, access, & quality.
4. Govt. may also be more than the payer but also serve as the provider directly delivering health care services to
specific patient populations such as veterans, Native Americans, & the indigent – when govt,. is the direct provider
of personal health services, it largely breaks out along these lines:

At fed. level, it is population-specific - provided to specific categories of persons such as veterans & Native
Americans
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At state level, it is disease-specific - mentally ill, TB

At local level, it is largely class-centered - indigent care
5. Govt. also funds & directs much medical research (i.e. NIH, CDC)
6. Responsible for public health priorities and programs - Emerson’s “Basic Six” services of public health at
state & local level: vital statistics, public health labs, communicable disease control, environmental health,
maternal & child health, and public health education – consensus with private health care sector that these
services are appropriate for state & local govt. involvement/delivery
Critical Concepts – Chapter 1
How did we end up with a system of employer-based health insurance?

“The revival of the company store for medicine has less to do with logic than pure chance. It is a wonderful
example of how one bad government policy leads to another. During World War II, the government financed much
wartime spending by printing money while, at the same time, imposing wage and price controls. The resulting
repressed inflation produced shortages of many goods and services, including labor. Firms competing to
acquire labor at government-controlled wages started to offer medical care as a fringe benefit. That benefit
proved particularly attractive to workers and spread rapidly. Initially, employers did not report the value of the
fringe benefit to the Internal Revenue Service as part of their workers’ wages. It took some time before the IRS
realized what was going on. When it did, it issued regulations requiring employers to include the value of medical
care as part of reported employees’ wages. By this time, workers had become accustomed to the tax exemption of
that particular fringe benefit and made a big fuss. Congress responded by legislating that medical care
provided by employers should be tax-exempt.” (Dr. Milton Friedman, 2001)

Why did managed care develop? 1) Emergence of belief in new financial formula for health care – reduced
utilization = reduced costs (shift profits from fee for service physician model to a managed care model so
physicians lose $ but MCOs make $) 2) Pre-approval for services could decrease utilization 3) MCOs felt they had
more leverage due to oversupply of physicians competing for business (they could impose more conditions on
providers who were happy to get a steady stream of business in a competitive environment) - historically,
“hospitals had doctors & doctors had patients” – now, the MCO has the patients and the hospitals/physicians are
the providers
Managed care seeks to Get control of payment, price, and utilization – integrate all 4 functions of health care
through managed care (financing, insurance, payment, & delivery) to control costs
What is managed care? A system of health care delivery that (1) seeks to achieve efficiencies by integrating the basic
functions of healthcare delivery, (2) employs mechanisms to control utilization of medical services and
3) determines the price at which the services are purchased and how much the providers get paid
Critical Concepts – Chapter 1
PRIMARY CHARACTERISTICS OF THE US HEALTHCARE SYSTEM – 10 defining characteristics which
differentiate the U.S. health care system from other countries
1. No central agency governs the system - global budgeting becomes impossible
2. Partial access – access is based on insurance coverage – a segment of the population (15%) is uninsured
3. Health care is delivered under imperfect market conditions – as a consumer, you don’t know price & performance
like you do with the purchase of other goods & services - moral hazard and supplier-induced demand
4. Third-party insurers and payers - insurance entities (commercial insurance companies or managed care
organizations) become an intermediary between the financing and delivery functions - this intermediary role results
in higher administrative costs.
5. Multiple payers make the system more complex and cumbersome.
6. Balancing of power among various players prevents any single entity from dominating the system
7. Legal risks influence practice behavior - legal actions lead to the practice of defensive medicine
8. Development of new technology creates an automatic demand for its use
9. New service settings have evolved along a continuum
10. Quality is no longer accepted as an unachievable goal in the delivery of health care
Critical Concepts – Chapter 1
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A global budget is a tool of public policy where the national government sets a nationwide cap for annual spending on all health care –
there are consequences to global budgets: 1) utilization has to be controlled 2) access to specialists and more expensive
treatments/technology will be restricted – in cross-national comparisons over national levels of health care spending, nations which
employ global budgets will always spend less than the U.S. where no single central entity such as the federal government annually caps
all health care spending
How is access to health care in the U.S. obtained? 1) those who have employer-based health insurance 2) those covered under a
government health program 3) those who can purchase insurance out of their own private funds 4) those who can pay for services out of
pocket 5) those who go to the ER
Health care in the U.S. does not operate as a free market - consumers lack information about price and quality/performance of
providers – there is limited choice and competition (often the result of government regulation and not market forces) – prices are often not
set by the market (i.e. prices set by MCOs or by the government payer) – the consumer is often not the payer – it is not a traditional
customer-producer market transaction – it is a 3rd party payer system - the consumer orders the service, the provider delivers it, and
someone else gets the bill
It is financed via insurance but insurance is designed for major expenses associated with an unlikely and unexpected event –
health care is a routine need, it is likely and predictable yet we utilize the insurance model to finance its delivery - There is a moral
hazard that once enrollees have purchased health insurance, they will utilize healthcare services. With insurance, patients are insulated
from the effects of the full cost of their decisions to utilize and consume health care services – “When it’s an open bar, everyone orders
top shelf brands.” (Dr. Bebber) – health insurance and a third party payer system contribute to the problem of moral hazard (people
behave differently when they are not paying out of pocket every time they use a service – encourages utilization – costs go up)
Insurance is premium paid based upon risk (risk sets rate - higher risk = higher premium & lower risk = lower premium) – when the
govt. legislates that insurers cannot know or calculate pre-existing conditions into setting premium, how can the insurance model operate
in the financing of health care? (disconnects risk from rate – higher risk customers will pay less than they should & lower risk customers
will pay more than they should)
Another symptom of an imperfect market is supplier-induced demand where those “who have a financial interest in additional
treatments also create artificial demand” (p. 15) – rather than the market generating demand, the producer inflates demand
The end result of third party payers and multiple payers is that the U.S. spends more on administrative costs than other health
care systems – combined cost of billing, collection, bad debts, & maintaining medical records
Critical Concepts – Chapter 1
Several factors converge which almost guarantee that the “latest and best” technology will be demanded and
utilized:
1) Patients are much more aware of medical technology compared to previous generations - patients now
basically “order” specific tests & treatments rather than the physician first telling them it should be done – this is a
new phenomenon compared to earlier generations – direct marketing of medical products via TV & other
advertising to consumers who have insurance & so they make the diagnosis and recommend the specific
treatment to their physician & they want the newest & best technology
2) Hospitals and physicians compete on the basis of having the latest technology
3) Concern over litigation may discourage providers & health plans from denying use of technology
4) Sunk costs – we made the capital expenditure – now, we have to recoup our investment through utilization
Three models of national systems:
1. National Health Insurance (NHI) – a tax-supported national healthcare program in which services are financed by
the government but are rendered by private providers. 3 of the 4 functions directly done by government – most
provinces utilize global budgets. (Canada)
2. National Health System (NHS) - tax-supported national healthcare program in which the government finances and
also controls the service infrastructure – government operates most medical institutions - providers are either
government employees or organized in a publicly managed institution - government oversees all 4 functions –
global budget (Great Britain).
3. Socialized Health Insurance (SHI) - health care is financed through government-mandated contributions by
employers and employees, health care is delivered by private providers, and private non-profit insurance
companies called sickness funds are responsible for collecting the contributions & paying the hospitals and
physicians – global budgets utilized – government in control of the system (Germany, Israel, and Japan).
Critical Concepts – Chapter 1
E-medicine – electronic health records (EHRs)/personal medical records (PMRs)/electronic information sharing
networks have been proposed to improve quality, reduce errors, & boost efficiency – most small private physician
practices still depend on paper records – the advent of e-medicine could facilitate better tracking of population
level health trends & further enable better identification of clinical interventions which hold the most promise –
reduce defensive medicine – permit a patient to walk into any clinic or hospital with their full medical records –
could encourage patients to become more active in their health/disease management - telehealth - physicians
communicating via the Internet - syndromic surveillance (monitor for epidemics) - many issues to overcome
(trust, technology, system security, cultural, leadership, privacy, etc.) - electronic information integration remains a
major challenge for U.S. health care
FINANCING AND INSURANCE MECHANISMS
1. Employer-based health insurance – private
2. Privately purchased health insurance – people purchase their insurance as individuals paying directly or they
self insure paying out of pocket as health needs arise
3. Government programs – public health insurance programs include:

Medicare - elderly and certain disabled people (age sets eligibility)

Medicaid – low income individuals (income sets eligibility) – this is a federal/state partnership (55% federal
paid/45% state paid in Florida - $16.2 billion of Florida’s budget in FY 09/10)

SCHIP - children from low-income families who are not eligible for Medicaid – this is a federal/state partnership
Chapter 2
Beliefs, Values, and
Health
Dr. Joe Saviak
Shi and Singh, Delivering Health Care in America: A Systems Approach
(2012, 2008)
Jonas, Goldsteen, & Goldsteen, An Introduction to the U.S. Health Care
System, 6th Edition, (2007)
Visuals by Google Images
Chapter 2
The values and beliefs of a society will influence its definitions of sickness and
health and the design and delivery of health care to its citizens
What are historically held major beliefs concerning health care in America?
1. Belief in science and technology - application of the scientific method to medicine.
The medical model of healthcare delivery is founded on advances in science and
technology. In turn, the medical model has led to the tremendous growth in medical
science and technological innovation.
2. Belief in private initiatives instead of government involvement to deliver health
care to most Americans - privately financed health insurance that is mainly
employment-based - publicly financed health insurance for the less fortunate
(Medicaid and Medicare)
3. Belief in individualism - responsibility for one’s own health and economic well-being
- achievement of health through personal means
4. Greater focus on individual health than population health (probably a function of
#2 & #3)
5. Health care has been viewed as an economic good to be delivered by market
means rather than a right or entitlement to be provided by government
Chapter 2
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Other societies may have different beliefs and values which have
shaped their health care system
The cultural context can be as important as the economic environment
of health care leading different societies to different priorities and
alternative policy choices
Americans have a set of beliefs, attitudes and expectations
concerning our health care
Chapter 2
The Medical Model strongly influences concepts of health and health care in the U.S. – what defines
the medical model?
 Defines health as the absence of illness or disease (rather than a broader definition of overall
wellness)
 The focus is curative (i.e. drugs, treatments, surgeries to relieve symptoms and discomfort –
treating an active disease) rather than preventive (restrain the development of disease or an
adverse health condition before it occurs – prenatal care, mammograms, immunization – not
treating an active disease)
 Presupposes the existence of illness or disease – once a person experiences discomfort or
symptoms, they seek care to find relief - focuses on diagnosis and relief of symptoms - clinical
intervention once disease is diagnosed - once relief is obtained, the person is considered well,
even if the disease is cured or not
 Health care = medical care
 Measurement of health status: use of morbidity and mortality measures – these are negative
measures of health but consistent with the medical model which emphasizes an absence
of disease, disability, or death
 Financing for services: traditionally, better coverage for curative services than preventive
services
 Training of health professionals is intervention-oriented, specialist-oriented – healthcare
personnel have been trained to concentrate on physical symptoms - produce more specialists to
diagnose and treat active disease and disability.
 Status of health professionals: higher status and incomes for specialists like the cardiologist
who relieves major discomfort and specific symptoms associated with active disease rather than
the primary care physician who has the opportunity to be more prevention-oriented
Chapter 2
Competing Perspectives on Health
Broader definitions of health – it’s more than just medical care for an active disease or present
symptoms/discomfort – the medical model would be a largely physical perspective on what
constitutes health – broader definitions include other dimensions of overall well being.
Society for Academic Emergency Medicine – “ a state of physical and mental well-being that
facilitates the achievement of individual and societal goals.”
The Social Model - incorporates the physical and social elements of health. A person’s ability to
perform the expected social roles (attending school, doing housework, going to work) is
interpreted as health. Seeking medical help is recommended when a person is physically
unable to perform his or her social tasks.
The World Health Organization definition – “a complete state of physical, mental, and social
well being and not merely the absence of disease or infirmity” - incorporates the physical,
mental, and social elements of health as necessary for individual well-being – the social aspect of
health recognizes that having a social support network is positively associated with life stresses,
self-esteem, & social relations.
Holistic Health – treat the whole person rather than just treat the disease or disability - includes
spiritual well-being along with the other three dimensions of the WHO definition of health.
Spirituality can have a positive impact on the individual’s overall health (important internal
resource to cope with illness). The spiritual dimension has become an important issue in several
areas of healthcare delivery, such as end-of-life care and long-term care – physicians may
encounter some challenges in appropriately addressing the spiritual aspect of these issues in the
lives of their patients.
Chapter 2
Medical Model – focus is on diagnosis and treatment - goal is relief of adverse symptoms –
reliant on drugs, treatment, & technology.
Wellness Model/Health Promotion/Disease Prevention Model (HPDP)
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Focus on prevention – goal is wellness - promotion of an optimum state of well-being and
prevention of disease

Utilizes means other than treatment or technology - education/health literacy, behavior
modification, immunization
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A key criticism of the medical model is that it has emphasized treatment rather than health
education and other means for reducing high-risk behaviors. The concern with non-health has
funneled most research efforts away from the pursuit of health into development of sophisticated
medical technology. One of the problems with the healthcare delivery system is that the
preponderance of healthcare expenditures are devoted to the treatment of medical
conditions—such as heart disease, cancer, and stroke—rather than to the prevention and
control of factors that produce those medical conditions in the first place.
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Instead of choosing between a medical model which emphasizes diagnosis and treatment and a
health promotion/disease prevention model (HPDP) which concentrates on prevention, the
solution might to integrate diagnosis and treatment with health education and disease prevention
– design and implement a health care system which incorporates both models (a hybrid)
and succeeds in both missions – curative and preventive. How do we design a system which
excels in both missions?
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Chapter 2
Illness vs. Disease
These terms are not synonymous although they are often employed
interchangeably

Illness - self-perceived – self diagnosed – I am not feeling well or am having trouble
with functions of daily life – symptoms can be successfully treated & individual
declared well although underlying cause of disease not cured - it reflects what a
person feels - it may not require therapeutic intervention & disease may or may not
be present.
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Disease – disease declared based on professional evaluation of a health care
professional - it reflects what is diagnosed by a physician, it requires therapeutic
intervention & the person may or may not feel ill.
A person can be diseased without feeling ill
One may feel ill & yet not have a disease.
Chapter 2
Understanding Disease
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Disease often caused by more than a single factor
Risk Factor - an attribute that increases the likelihood (probability) that people
would develop a disease or a negative health condition. A risk factor may or
may not cause disease; it merely raises the probability of acquiring a
disease. Preventive interventions are designed to eliminate risk factors to
decrease occurrence of disease and promote health.
Epidemiology – “the study of the nature, cause, control, and determinants of
the frequency and distribution of disease, disability, and death in human
populations” (Timmreck, 1994, p. 2)
Chapter 2
The Epidemiology Triangle – see Figure 2-2 on p. 42
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Host - person exposed to the agent and at risk of developing a disease; factors
associated with the host are genetic makeup, level of immunity, fitness, personal
behaviors which contribute to contracting the agent or making the agent active – for
the host to be ill, the agent must be present although presence of an agent does not
guarantee that disease will occur
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Agent - a factor responsible for producing disease; agents include
bacteria/viruses, chemical agents, radiation, dietary excesses, nutritional deficiencies

Environment - set of conditions that directly or indirectly are responsible for
exposing the host to the agent – external to the host and can enhance or reduce
likelihood of exposure to the agent – includes the physical, social, cultural, &
economic aspects of the environment - physical (sanitation, air pollution); social
conditions (violence, emotional abuse, peer pressure); cultural beliefs and values;
and economic factors
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These 3 factors interact to produce disease

Need to design and implement strategies to counteract these risk factors

The health strategy or intervention must match the specific risk factor so as to
eliminate or reduce it with the goal of disease reduction and health promotion
Chapter 2
Two major types of appropriate interventions to counteract key risk factors are behavior
modification and therapeutic interventions.
Behavioral Risk Factors:
 Smoking - is leading cause of preventable disease and death in the U.S. because It significantly
increases risk of heart disease, stroke, lung cancer, and chronic lung disease
 Substance abuse
 Lack of physical exercise
 High fat diet
 Improper use of motor vehicles
 Unsafe intimate relations
Behavior modification is achieved by means of:
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Education
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Personal motivation
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Financial incentives (tax on cigarettes)
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Environmental inducements (advertising, role models)
 Major employers have successfully contained costs within their insured employee
population through effective behavior modification programs (annual health insurance costs
have risen by 12-15% in recent years yet some employers have kept their annual premium
increase within the COLA 3-5%) through wellness programs, disease management programs, and
increasing the health literacy of their employees – behavior modification can improve health and
contain costs
Chapter 2
Another appropriate health strategy to counteract key risk factors are therapeutic interventions:
Three levels of therapeutic interventions:

Primary prevention - interventions designed to minimize the probability of disease
developing in the future – restrain the development of a disease or negative health condition
before it occurs (immunization, diet control, exercise programs, work safety programs) –
“immunization has had a greater impact on prevention on childhood diseases and mortality
reduction than any other public health intervention besides clean water” (p. 44) – hand washing,
refrigeration of foods, garbage collection, & protection of the water supply are forms of primary
prevention of disease – stop it before it ever starts

Secondary prevention - early detection and treatment of disease – goal is to block the
progress of disease or an injury from developing into impairment or disability – examples of
secondary prevention include health screening, for example, blood pressure, blood sugar levels,
cholesterol screening, mammography, pap smears – prevent it from becoming full blown disease
or disability once it has started

Tertiary prevention – rehabilitation, prevention of further complications , prevention of
problems which can arise through the health care process and monitoring for prevention
of further illness, injury or disease – examples would be restorative therapies and infection
control procedures in healthcare institutions to protect against nosocomial infections (hospital
induced infections) – these are also practices designed to prevent iatrogenic diseases which are
illnesses or injuries caused by the process of health care (turn bed bound patients to prevent
sores) – might also include behavior modification to prevent recurrence of the disease – can’t
prevent or reverse it but can try to manage it and prevent further problems associated with the
disease or disability
Chapter 2
Prevention, detection, and treatment works – for example, this strategy helped reduce
cancer mortality rates pretty significantly between 1991-1995 (Table 2-2 – prostate
cancer mortality declined by 6.3% in this 5 year period)
Disease Classifications: Acute, Subacute, and Chronic
Acute - relatively severe, episodic (of short duration) and often treatable - treatments
generally provided in a hospital – examples of acute conditions would include
myocardial infarction (heart attack) or sudden kidney interruption
Subacute – between acute and chronic but has some acute features – can include
postacute treatment after discharge – examples of subacute conditions would be use
of a ventilator or head trauma care
Chronic - less severe, but long and continuous duration – disease managed/controlled or
put into remission but not completely cured – left untreated, it can lead to severe and
life threatening problems – examples of chronic conditions would include asthma,
diabetes, hypertension
Chapter 2
The Wellness Model
Based on disease prevention & health promotion
3 factors in the Wellness Model:
1. Understand risk factors associated with host, agents, & environment & know their
consequences – conduct a health risk appraisal which is the process of evaluating
risk factors and their health consequences in individuals. Only when the risk factors
and their health consequences are known can avenues be developed for motivating
individuals to alter their behaviors to more healthful patterns.
2. Intervention – designed to counteract risk factors – may be behavior modifications
or therapeutic interventions (primary, secondary, tertiary prevention)
3. Adequate public health and social services – minimize risk factors & their effects –
prevent disease & contain outbreaks - maximize health of the population
Chapter 2
Developmental Health
Development – growth in skill and capacity to function normally
 Early childhood development is an important factor that influences behavior
 Can have a profound influence on health and adjustment to life in later years.
 Expectant mothers need adequate prenatal care - the health promotional needs of
the expectant mother and the fetus are so intimately intertwined that they must be
considered
 A second area of emphasis is adequate childcare - immunization, nutrition, and
health care are also key developmental elements until a child reaches adulthood.
 Preventable developmental disabilities impose an undue burden on the healthcare
delivery system.
Chapter 2
Public Health

Seeks to apply current knowledge of health and disease in ways that will have the
maximum impact on a population’s health status - the science and art of
preventing disease, prolonging life, and promoting health and efficiency
through organized community effort - public health is concerned with ensuring
conditions that promote optimum health for society as a whole

“Public Health is what we, as a society, do collectively to assure the conditions
in which people can be healthy…” (Institute of Medicine, 1988)

Govt. Role in Providing Community Health Services – govt. at all 3 levels may
share responsibility for multiple public health services such as environmental
protection, inspection & regulation of food & drugs, preventing/containing outbreaks
of communicable diseases, collection of health data/vital statistics, & conduct of
health care research

At the state and local levels of government, public health concentrates on Emerson’s
“Basic Six” services: 1) vital statistics, 2) public health labs, 3) communicable
disease control, 4) environmental health, 5) maternal & child health, and
6) public health education – consensus with private health care sector that these
services are appropriate for state and local govt. involvement/delivery
Chapter 2
Three Major Public Health Functions:
1) Prevention
2) Health Promotion
3) Health Protection – relatively new role due to 20th century industrialization – this role
can be seen in:
 Environmental Protection Agency (EPA) – environmental health
 Occupational Safety and Health Administration (OSHA) – workplace safety
 Bioterrorism, Homeland Security Act 2002: the use of chemical, biological &
nuclear agents to harm populations - training, Civil Defense, countermeasures &
cooperation between interagency groups
Chapter 2
How would we describe the differences between the practice of medicine and the
discipline of public health?
Medicine
 Focuses on the individual patient, biological causes of disease with treatment,
treat disease and recover health
 Involves physicians, nurses, dentists, therapists, social workers, psychologists,
nutritionists, health educators, pharmacists, laboratory, administration
Public Health
 Focuses on populations, understand environment (physical, social &
behavioral) then develop population-based interventions, prevent disease and
promote health through social marketing, provides education to pass laws,
disseminate information
 Involves the health care professionals listed above plus sanitarians, epidemiologists,
statisticians, hygienists, environmental health specialists, food/drug inspectors,
toxicologists, and economists
Since problem definition influences our solutions/public policy responses, when do we
define an issue as a problem of individual health vs. a problem of public health?
Who makes that decision?
Chapter 2
Quality of Life

A key measure of health outcomes
Overall satisfaction with life during and following a person’s encounter with the
health care delivery system:
1. An indicator of how satisfied a person was with the experiences while receiving
health care – in terms of comfort, respect, privacy, security, autonomy
2. A person’s overall satisfaction with life and self-perceptions of health after a
medical intervention
The goal for the health care system is to have a have a positive effect on an individual’s
ability to function, ability to meet obligations, & feeling of self-worth
Chapter 2
Determinants of Health
Health status determined by a confluence of factors which comprise 4 major categories:
1) a person’s individual behaviors
2) genetic make-up
3) medical practice
4) the environment
CDC (1979) – examined premature deaths to identify causes - the CDC would identify individual
lifestyles and behaviors as the leading culprit for premature death –
1) individual lifestyles and behaviors – 50%
2) genetic predisposition – 20%
3) inadequate access to medical care – 10%
4) social/environmental factors – 20%
*it would be interesting to see this same study replicated today (30 years later)
Blum (1981) – his health focus is overall well being – his leading suspect is the environment
(physical, social, cultural, and economic factors) - the Blum model points to four key determinants
of health: environment, lifestyles or individual behaviors (behaviors/attitudes towards health), a
person’s genetic makeup or heredity, and medical care (he terms them the 4 force-fields). These
four elements are interactive - the four must be considered simultaneously when addressing the
health status of individuals or populations.
Chapter 2
Determinants of Health
It should be noted as Blum does that these determinants of health are interactive and
produce health consequences through their interaction rather than solely by single
and independent influence
Different determinants may be more or less at influential at different times in an
individual’s life – “health before age 60 is determined by what you do to yourself but
after age 60, it’s genetics” (Gordy, 2010)
The main implication of these health determinants is that the healthcare delivery
system must go beyond the medical model in order to achieve optimum health
– don’t focus solely on medical care (medical model) because even if it improved, it
would not solve your problem and significantly improve the health status of your
overall population – for example, providing comprehensive, continuous, and
coordinated primary care to a population could yield better overall health
outcomes than any other single strategy.
Integrate the medical model with the wellness model & address both individual and
population level health needs and outcomes.
Chapter 2
Why is it important to develop valid and reliable measures of health status and then collect and
analyze the data using these measures? (also measure demographic changes/trends)
 When health problems are clearly identified, managers and policymakers can plan efforts
and apply resources where they will produce the greatest benefit. For example, high
incidence rates of an infectious disease may indicate an impending epidemic for which public
health officials can develop strategies.
 Use of specific rates for morbidity and mortality can pinpoint areas where healthcare efforts
should be directed. A particular minority group, for instance, may have higher rates of a
particular condition that may require targeted interventions.
 Demographic change can have serious implications for health policy. For example, the
migration of the elderly to the southern states will require planning of adequate retirement and
long-term care services.
 Measures of utilization can be used to determine which individuals among a population
group receive certain types of medical services, which ones do not receive services, and
why. A healthcare provider, such as a hospital, can find out the extent to which its services are
used.
 Measures of utilization can help managers decide whether certain services should be
added or eliminated.
 Health planners can determine whether certain programs have been effective in reaching
their targeted populations. Hence, measures of utilization play a critical role in the planning of
health delivery capacity, such as in determining how many hospital beds are required to meet the
acute care needs of a given population.
Chapter 2
Measures of Health Status
 Health status - at the individual and population levels can be measured in several
ways – first, we have to develop valid and reliable measures and then we have to
regularly collect the data over time
 We often rely on “negative” measures of health status – morbidity (disease)
and mortality (death) – this is consistent with the medical model approach to health
care – health status and longevity represent positive measures – there is a need to
develop more positive measures so we have the most comprehensive & accurate
understanding of health status
 Self-perceived health status (ask respondent to rate their health) tends to highly
correlate with more objective measures of health status
Measures of Longevity
Life expectancy - a prediction of how long a person will live
Life expectancy at birth - how long a newborn can expect to live
Life expectancy at age 65 - expected remaining years of life for a 65 year old
Chapter 2
Measures of Morbidity (disease or disability)
At risk population - all people in the same community or group who can acquire a
disease or a condition
Incidence = number of new cases occurring in the population at risk within a specified
time period – tells us the extent to which people who do not have the disease develop
the disease in a given population in a specified period of time
Epidemic = Large number of people who acquire a specific disease from a common
source
Prevalence = Measure the total number of cases at specific point in time / specified
population
Measures of Mortality
Mortality - the term used in the measurement of death rates
Crude Death Rate = Total deaths / Total population
Age Specific = number of deaths within a certain age group / Total # of persons in that
age group
Cause Specific = # of deaths from a specific disease / Total population
Infant Mortality = number of deaths from birth to one year of age / # of live births that
same year
Chapter 2
Measures of Health Status
Measures of Disability
Activities of daily living (ADLs) - Measure a person’s ability to function independently,
especially in reference to one’s ability to perform six basic activities: eating, bathing,
dressing, toileting, maintaining continence, and getting into or out of a bed or chair.
Instrumental activities of daily living (IADLs) - Used in reference to a person’s ability
to perform activities that are necessary for living independently in the community,
such as preparing meals, shopping for routine items, managing money, and
housekeeping.
Utilization
The consumption of health care services or the extent to which health care
services are used
Chapter 2
Discuss the main elements of Parsons’s sick role model. What implications does the sick role
model have for health services delivery?

Parsons’s sick role model views illness as a socially institutionalized role type, which has four
specific features: (1) Sick individuals are not held responsible for their sickness. (2) Being sick is
recognized as the legitimate basis for society to exempt individuals from their social role
obligations. (3) Sick individuals are exempted from social roles on the condition that they
recognize that being sick is undesirable, and that they have the obligation to try to get well.
(4) Sick individuals must seek competent help and cooperate with medical agencies in their
attempts to help the individuals get well.
The model has two important implications for healthcare delivery:

First, the primary focus is on the individual. Societal roles are mainly passive, such as
agreeing to release an individual from his or her social obligations. More importantly, society is not
required to furnish medical services. It is up to the sick individual to seek appropriate medical care
and comply with the prescribed regimen. The model assumes that health-seeking behavior is
determined by individual capacity to obtain care, such as through health insurance coverage.

Secondly, the social model assumes that the sick role obligations will be carried out within
the context of the medical model of health services delivery. Society does not hold the
individual responsible for his or her diseased condition even though certain lifestyles and
behaviors can substantially increase the risk of high cost illness
Chapter 2
How should we as a society provide access to health care? Shi and Singh (2008) approach this
issue through the framework which they term market justice vs. social justice
Market Model

Health care is an economic good governed by free market forces and supply and demand the production of health care is determined by how much the consumers are willing and able to
buy at the prevailing price

Medical services distributed on the basis of people’s willingness and ability to pay.

Individuals are generally responsible for their own health and economic well being and
decisions

People make rational choices in their decision to buy health care products and services - people
consult with their physicians to know what is best for them

The market works best without interference from government

A physician is duty-bound to do whatever is necessary to restore a patient’s health - an individual
is responsible for paying the physician for his/her service

The indigent can be served by charity or public programs

Those not able to pay have barriers to health care - “rationing by ability to pay” - healthcare
services are rationed through prices and the ability to pay - the uninsured and those who lack
sufficient income to pay privately cannot obtain the quantity and type of healthcare services they
need when they want them - referred to as “rationing by ability to pay,” demand-side rationing, or
price-rationing.

Focus on individual rather than a collective responsibility for health
Chapter 2
Social Justice Model

Theory is at odds with capitalism and market justice

The equitable distribution of health care is society’ responsibility - best when a
central agency is responsible for the production and distribution of health care

Health care is a social good - should be collectively financed and available to
every citizen.

Health care should be based on need rather than cost

There is a shared responsibility for health - factors outside a person’s control might
have brought on the condition

There is an obligation to the collective good - the well being of the community
is superior than that of the individual

Government rather than the market can better decide - through planning how
much health care to provide and how to distribute among all citizens.

Under social justice, the government makes deliberate attempts, often referred
to as “health planning,” to limit the supply of healthcare services, particularly
those beyond the basic level of care. For example, how technology should be
dispersed and who should be allowed access to certain types of high-tech services
are based on government planning. This is referred to as planned rationing,
supply-side rationing, or non-price rationing.
Chapter 2







Market justice views health care as an economic good delivered under free-market conditions. It
assumes that markets are more efficient in allocating health resources equitably. The
distribution of medical care services and access to them are determined by people’s ability to pay.
Social justice views health care as a social resource. It requires active government
involvement in the delivery of health care under the assumption that the government is
more efficient in allocating health resources equitably. Medical care is regarded as a basic
right; all citizens have equal access to medical care, and ability to pay is inconsequential.
Healthcare delivery in the United States is characterized as a quasi- or imperfect market.
Hence, we find elements of both market justice and social justice.
In some areas, the principles of market justice and social justice complement each other.
In other areas, the two are in conflict.
The principles of market justice and social justice complement each other with private,
employer-based health insurance for mainly middle-income Americans (market justice),
and publicly financed Medicaid and Medicare coverage for certain disadvantaged groups,
and workers’ compensation for those injured at work (social justice).
The two principles collide, however, in regard to the uninsured who cannot afford to
purchase private health insurance and do not meet the eligibility criteria for Medicaid or
Medicare.
The two principles complement each other when private and government health insurance
programs enable the covered populations to have access to healthcare services delivered
by private practitioners and private institutions (market justice). Tax-supported county
hospitals or city hospitals in large cities, public health clinics, and community health
centers can be accessed by the uninsured in areas where such services are available
(social justice).
Chapter 2
Class Discussion

So who’s right? Which model would you adopt? Would you select a hybrid
model with elements of both?

Are those all the arguments in favor and in opposition of the market and
government models for the financing and delivery of health care in a society?

How well does each of these models work?

What does the evidence tell us about each of these models?
Critical Concepts – Chapter 2
The medical model strongly influences concepts of health and health care in the U.S. – what defines
the medical model?
 Defines health as the absence of illness or disease (rather than a broader definition of overall
wellness)
 The focus is curative (i.e. drugs, treatments, surgeries to relieve symptoms and discomfort –
treating an active disease) rather than preventive (restrain the development of disease or an
adverse health condition before it occurs – prenatal care, mammograms, immunization – not
treating an active disease)
 Presupposes the existence of illness or disease – once a person experiences discomfort or
symptoms, they seek care to find relief - focuses on diagnosis and relief of symptoms - clinical
intervention once disease is diagnosed - once relief is obtained, the person is considered well,
even if the disease is cured or not
 Health care = medical care
 Measurement of health status: use of morbidity and mortality measures – these are negative
measures of health but consistent with the medical model which emphasizes an absence
of disease, disability, or death
 Financing for services: traditionally, better coverage for curative services than preventive
services
 Training of health professionals is intervention-oriented, specialist-oriented – healthcare
personnel have been trained to concentrate on physical symptoms - produce more specialists to
diagnose and treat active disease and disability.
 Status of health professionals: higher status and incomes for specialists like the cardiologist
who relieves major discomfort and specific symptoms associated with active disease rather than
the primary care physician who has the opportunity to be more prevention-oriented
Critical Concepts – Chapter 2
Competing Perspectives on Health
Broader definitions of health – it’s more than just medical care for an active disease or present
symptoms/discomfort – the medical model would be a largely physical perspective on what
constitutes health – broader definitions include other dimensions of overall well being.
Society for Academic Emergency Medicine – “ a state of physical and mental well-being that
facilitates the achievement of individual and societal goals.”
The Social Model - incorporates the physical and social elements of health. A person’s ability to
perform the expected social roles (attending school, doing housework, going to work) is
interpreted as health. Seeking medical help is recommended when a person is physically
unable to perform his or her social tasks.
The World Health Organization definition – “a complete state of physical, mental, and social
well being and not merely the absence of disease or infirmity” - incorporates the physical,
mental, and social elements of health as necessary for individual well-being – the social aspect of
health recognizes that having a social support network is positively associated with life stresses,
self-esteem, & social relations.
Holistic Health – treat the whole person rather than just treat the disease or disability - includes
spiritual well-being along with the other three dimensions of the WHO definition of health.
Spirituality can have a positive impact on the individual’s overall health (important internal
resource to cope with illness). The spiritual dimension has become an important issue in several
areas of healthcare delivery, such as end-of-life care and long-term care – physicians may
encounter some challenges in appropriately addressing the spiritual aspect of these issues in the
lives of their patients.
Critical Concepts – Chapter 2




Medical Model – focus is on diagnosis and treatment - goal is relief of adverse symptoms –
reliant on drugs, treatment, & technology.
Wellness Model/Health Promotion/Disease Prevention Model (HPDP) – focus on prevention –
goal is wellness - promotion of an optimum state of well-being and prevention of disease – utilizes
means other than treatment or technology (i.e. education/health literacy, behavior modification,
immunization)
A key criticism of the medical model is that it has emphasized treatment rather than health
education and other means for reducing high-risk behaviors. The concern with non-health has
funneled most research efforts away from the pursuit of health into development of sophisticated
medical technology. One of the problems with the healthcare delivery system is that the
preponderance of healthcare expenditures are devoted to the treatment of medical
conditions—such as heart disease, cancer, and stroke—rather than to the prevention and
control of factors that produce those medical conditions in the first place.
Instead of choosing between a medical model which emphasizes diagnosis and treatment and a
health promotion/disease prevention model (HPDP) which concentrates on prevention, the
solution might to integrate diagnosis and treatment with health education and disease prevention
– design and implement a health care system which incorporates both models (a hybrid)
and succeeds in both missions – curative and preventive. How do we design a system which
excels in both missions?
Critical Concepts – Chapter 2
Behavioral Risk Factors:

Smoking - is leading cause of preventable disease and death in the U.S. because It significantly increases risk of heart disease, stroke,
lung cancer, and chronic lung disease

Substance abuse

Lack of physical exercise

High fat diet

Improper use of motor vehicles

Unsafe intimate relations
Behavior modification is achieved by means of:

Education

Personal motivation

Financial incentives (tax on cigarettes)

Environmental inducements (advertising, role models)
Therapeutic Interventions:
Primary prevention - interventions designed to minimize the probability of disease developing in the future – restrain the development of a
disease or negative health condition before it occurs (immunization, diet control, exercise programs, work safety programs) –
“immunization has had a greater impact on prevention on childhood diseases and mortality reduction than any other public health
intervention besides clean water” (p. 44) – hand washing, refrigeration of foods, garbage collection, & protection of the water supply are
forms of primary prevention of disease
Secondary prevention - early detection and treatment of disease – goal is to block the progress of disease or an injury from developing into
impairment or disability – examples of secondary prevention include health screening, for example, blood pressure, blood sugar levels,
cholesterol screening, mammography, pap smears
Tertiary prevention – rehabilitation, prevention of further complications which can arise through the health care process and monitoring for
prevention of further illness, injury or disease – examples would be restorative therapies and infection control procedures in healthcare
institutions to protect against nosocomial infections (hospital induced infections) – these are practices designed to prevent iatrogenic
diseases which are illnesses or injuries caused by the process of health care (turn bed bound patients to prevent sores) – might also
include behavior modification to prevent recurrence of the disease
Critical Concepts – Chapter 2
3 factors in the Wellness Model:
1. Understand risk factors associated with host, agents, & environment & know their consequences – conduct a
health risk appraisal which is the process of evaluating risk factors and their health consequences in individuals.
Only when the risk factors and their health consequences are known can avenues be developed for motivating
individuals to alter their behaviors to more healthful patterns.
2. Intervention – designed to counteract risk factors – may be behavior modifications
or therapeutic interventions (primary, secondary, tertiary prevention)
3. Adequate public health and social services – minimize risk factors & their effects – prevent disease & contain
outbreaks - maximize health of the population
Public Health
At the state and local levels of government, public health concentrates on Emerson’s “Basic Six” services: vital
statistics, public health labs, communicable disease control, environmental health, maternal & child health, and
public health education – consensus with private health care sector that these services are appropriate for state
and local govt. involvement/delivery
Quality of Life
Overall satisfaction with life during and following a person’s encounter with the health care delivery system:
1. An indicator of how satisfied a person was with the experiences while receiving health care – in terms of comfort,
respect, privacy, security, autonomy
2. A person’s overall satisfaction with life and self-perceptions of health after a medical intervention
Critical Concepts – Chapter 2
Health status determined by a confluence of factors which comprise 4 major categories:
1) a person’s individual behaviors
2) genetic make-up
3) medical practice
4) the environment
CDC (1979) – examined premature deaths to identify causes - the CDC would identify individual lifestyles and
behaviors as the leading culprit for premature death –
1) individual lifestyles and behaviors – 50% 2) genetic predisposition – 20%
3) inadequate access to medical care – 10% and 4) social/environmental factors – 20% - it would be interesting to
see this same study replicated today (30 years later)
Blum (1981) – his health focus is overall well being – his leading suspect is the environment (physical, social,
cultural, and economic factors) - the Blum model points to four key determinants of health: environment, lifestyles
or individual behaviors (behaviors/attitudes towards health), a person’s genetic makeup or heredity, and medical
care (he terms them the 4 force-fields). These four elements are interactive - the four must be considered
simultaneously when addressing the health status of individuals or populations.
It should be noted as Blum does that these determinants of health are interactive and produce health consequences
through their interaction rather than solely by single and independent influence
Different determinants may be more or less at influential at different times in an individual’s life – “health before
age 60 is determined by what you do to yourself but after age 60, it’s genetics”
The main implication of these health determinants is that the healthcare delivery system must go beyond the
medical model in order to achieve optimum health
Critical Concepts – Chapter 2
Measures of Health Status

Health status - at the individual and population levels can be measured in several ways – first, we have to
develop valid and reliable measures and then we have to regularly collect the data over time

We often rely on “negative” measures of health status – morbidity (disease) and mortality (death) – this is
consistent with the medical model approach to health care – health status and longevity represent positive
measures – there is a need to develop more positive measures so we have the most comprehensive & accurate
understanding of health status

Self-perceived health status (ask respondent to rate their health) tends to highly correlate with more
objective measures of health status
Discuss the main elements of Parsons’s sick role model.

Parsons’s sick role model views illness as a socially institutionalized role type, which has four specific features:
(1) Sick individuals are not held responsible for their sickness. (2) Being sick is recognized as the legitimate basis
for society to exempt individuals from their social role obligations. (3) Sick individuals are exempted from social
roles on the condition that they recognize that being sick is undesirable, and that they have the obligation to try to
get well.
(4) Sick individuals must seek competent help and cooperate with medical agencies in their attempts to help the
individuals get well.
Healthcare delivery in the United States is characterized as a quasi- or imperfect
market. Hence, we find elements of both market justice and social justice.