Changing the U. S. Health Care System: Key Issues in Health Services Policy and Management / Edition 2

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The third edition of Changing the U.S. Health Care System is a thoroughly revised and updated compendium of the most current thought on three key components of health care policy—improving access, ensuring quality, and controlling costs. Written by a panel of health care policy experts, this third edition highlights the most recent research relevant to health policy and management issues. New chapters address topics such as the disparities in health and in health care, information systems, and performance in the area of nursing. Revisions to chapters from the previous edition emphasize the most recent developments in the field.

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Editorial Reviews

Doody's Review Service
Reviewer: Eugene C. Rich, MD (Creighton University Medical Center)
Description: This multi-authored work is organized around five key themes in U.S. health policy: access; cost; quality; special populations; and options for health system reform.
Purpose: The authors' stated goal is to "take a comprehensive and careful look at current issues in health care policy and management." This worthy purpose is skillfully accomplished in this comprehensive work.
Audience: The proposed audience includes students in healthcare policy and management, health services researchers, health policy experts, healthcare managers, and practitioners (especially physicians and nurses).
Features: This superb book provides a thorough and authoritatve overview of the complex US healthcare system. There are excellent chapters on such diverse topics as Policies to Extend ...Coverage (a brief history of health insurance), Measuring Health care Costs, Pharmaceutical Prices, Evaluating the Quality of Care, and Medicare Reform. Completed in late 2000 (with copyright 2001), it inevitably presents some details now out-dated (e.g. HCFA is now CMS; the Federal budget surplus has evaporated, etc).The topics and chapters are so well conceived that the material remains highly informative and relevant despite these minor lapses.
Assessment: This outstanding, comprehensive resource on the U.S. healthcare system is sure to be of great value to students, educators, and scholars. Given the rapid changes in healthcare financing, provider organizations, and medical and administrative technologies, this second edition is a welcome improvement.
Researchers working in health policy from a wide range of perspectives summarize existing empirical research on their specialties and discuss research and management strategies that can be used to address current problems. Those whose chapter were carried over from the first edition (no date noted) were asked to emphasize developments since then. The 20 studies cover access, costs, quality, special populations, and directions for change. Annotation c. Book News, Inc., Portland, OR (
"The authoritative book on the U.S. health care system. Any student, scholar, executive, or policymaker who wants to understand a particular phenomenon should consult it."
--Deborah A. Freund, vice chancellor and provost, professor of public administration, Syracuse University

"Under one cover can be found the basic data and research relevant to virtually all important health policy issues, as well sophisticated analytic material on current problems and their range of possible solutions."
--Steven A. Schroeder, M.D., president and CEO, The Robert Wood Johnson Foundation

4 Stars! from Doody
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Product Details

  • ISBN-13: 9780787954048
  • Publisher: Wiley, John & Sons, Incorporated
  • Publication date: 1/28/2001
  • Series: Health Series
  • Edition description: Older Edition
  • Edition number: 2
  • Pages: 608
  • Product dimensions: 7.18 (w) x 9.48 (h) x 1.75 (d)

Meet the Author

Ronald M. Andersen is the Wasserman Professor Emeritus in the University of California, Los Angeles, department of Health Services and Sociology. Previously he was professor at the University of Chicago and director of Center for Health Administration Studies.

Thomas H. Rice is vice chancellor for academic personnel at the University of California, Los Angeles and professor of health services, University of California, Los Angeles, School of Public Health.

Gerald F. Kominski is professor in the Department of Health Services, associate dean for academic programs, and associate director of the Center for Health Policy Research at the University of California, Los Angeles School of Public Health.

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Read an Excerpt

Chapter 1: Improving Access To Care In America

Individual and Contextual Indicators

Ronald M. Andersen and Pamela L. Davidson

The purpose of this chapter is to present basic trends as well as research and policy issues related to health care access. We define access as actual use of personal health services and everything that facilitates or impedes their use. It is the link between health services systems and the populations they serve. Access means not only getting to service but also getting to the right services at the right time to promote improved health outcomes.

Conceptualizing and measuring access is the key to understanding and making health policy in a number of ways: (1) predicting use of health services, (2) promoting sociaI justice, and (3) improving effectiveness and efficiency of health service delivery.

The chapter presents a conceptual framework for understanding the multiple dimensions of access to medical care. The various types of access are considered and related to their policy purposes. Examples of key access measures are given and trend data are used to track changes that have occurred over time in these access indicators. The chapter addresses the questions, Is access improving or declining in the United States? For whom? According to what measures? It concludes by discussing future access indicators and research directions.

Understanding Access to Health Care

This section proposes a conceptual framework based on a behavioral model of health services use that emphasizes contextual as well as individual determinants of access to medical care. Also reviewed are the dimensions of access defined according to components of the framework and how access might be improved for each dimension.

Conceptual Framework

Compared to the framework presented in the first edition of this volume, the version shown in Figure 1.1 stresses that improving access to care is best accomplished by focusing on contextual as well as individual determinants.' By contextual we point to the circumstances and environment of health care access. Context includes health organization and provider-related factors as well as community characteristics.2 Contextual factors are measured at some aggregate rather than at the individual level. These aggregate levels range from units as small as the family to those as large as a national health care system. In between are workgroups, provider organizations, health plans, local communities, and metropolitan statistical areas. Individuals are related to these aggregate units through either membership (family, workgroup, provider institutions, health plan) or residence (community, metropolitan area, national health system).

The model shown in Figure 1.1 suggests that the major components of contextual characteristics are divided in the same way as individual characteristics determining access: (1) existing conditions that predispose people to use or not use services even though these conditions are not directly responsible for use, (2) enabling conditions that facilitate or impede the use of services, and (3) need or conditions recognized by laypeople or health care providers as requiring medical treatment.3 The model shown in Figure 1.1 emphasizes contextual factors in recognition of the importance of community, the structure and process of providing care,4 and the realities of a managed care environment.5 Still, the ultimate focus of the model remains on health behaviors of individuals (especially their use of health services) and resulting outcomes regarding their health and satisfaction with services. We now turn to brief consideration of each major component of the model shown in Figure 1.1.

Contextual Predisposing Characteristics. Demographic characteristics include the age, gender, and marital status composition of a community. Thus, a community populated primarily by older persons might well have a different mix of available health services and facilities than one in which the majority are younger parents and children.

,Social characteristics at the contextual level describe how supportive or detrimental the communities where people live and work might be to their health and access to health services. Relevant measures include educational levels, ethnic and racial composition, proportion of recent immigrants, employment levels, and crime rates.

Beliefs refer to underlying community or organizational values and cultural norms and prevailing political perspectives regarding how health services should be organized, financed, and made accessible to the population.

Contextual Enabling Characteristics. Health policies are authoritative decisions made pertaining to health or influencing the pursuit of health. They can be public policies made in the legislative, executive, or judicial branches of government, at all levels from local to national. They can also be policies made in the private sector by such decision makers as executives of managed care organizations concerning product lines, pricing, or marketing, or by accrediting agencies such as the Joint Commission on Accreditation of Health Care Organizations JCAHO) or quality assessment organizations such as the National Committee for Quality Assurance (NCQA).

Financing characteristics are described by an array of contextual measures that suggest resources potentially available to pay for health services, including per capita community income, and wealth. Other financial characteristics are incentives to purchase or provide services such as rate of health insurance coverage, relative price of medical care and other goods and services, and method of compensating providers. Also included here are per capita expenditures for health services.

Organization at the contextual level includes the amount and distribution of health services facilities and personnel as well as how they are structured to offer services. Structure includes supply of services in the community such as the ratios of physicians and hospital beds to population. Structure also includes how medical care is organized in a particular institution or delivery system where people receive care, such as office hours and location of service, provider mix, utilization and quality control oversight, and outreach and education programs.

Contextual Need Characteristics. Environmental need characteristics include healthrelated measures of the physical environment, among them the quality of housing, water, and air (for example, residing in counties that met national ambient air quality standards throughout the year).? Other measures suggesting how healthy the environment might be are injury and death rates, such as rate of occupational injury and disease and related deaths as well as death rates from motor vehicle injuries, homicides, and firearms...

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Table of Contents

Figures and Tables
The Authors
Introduction and Overview
Pt. 1 Access to Health Care 1
1 Improving Access to Care in America: Individual and Contextual Indicators 3
2 Public Policies to Extend Health Care Coverage 31
Pt. 2 Costs of Health Care 59
3 Measuring Health Care Costs and Trends 61
4 Containing Health Care Costs 82
5 Pharmaceutical Prices and Expenditures 100
Pt. 3 Quality of Health Care 125
6 Measuring Outcomes and Health-Related Quality of Life 127
7 Evaluating the Quality of Care 150
8 Public Release of Information on Quality 183
Pt. 4 Special Populations 203
9 Long-Term Care and the Elderly Population 205
10 AIDS in the Twenty-First Century: Challenges for Health Services and Public Health 224
11 Health Reform for Children and Families 261
12 Mental Health Services and Policy Issues 291
13 Women's Health: Key Issues in Access to Insurance Coverage and to Services Among Nonelderly Women 320
14 Homeless Persons 332
Pt. 5 Directions for Change 387
15 Managed Care and the Growth of Competition 389
16 Medicare Reform 406
17 The Role of Prevention 436
18 Public Health and Personal Health Services 457
19 The Continuing Issue of Medical Malpractice Liability 470
20 Ethical Issues in Public Health and Health Services 503
Name Index 537
Subject Index 539
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